Social Security stresses that a complete consultative exam (CE) report “will involve all the elements of a standard examination in the applicable medical specialty,” but many times there are significant elements missing from the report. Social Security sets-up CE examines with a doctor of the agency’s choosing if there does not appear to be enough medical evidence to make a disability decision. Although CE reports are supposed to include all of the following elements, many times these exams are less than 30 minutes long and are not through exams. Even so, here is what is supposed to be included in a CE exam:
- the claimant’s major or chief complaint(s);
- a detailed description, within the area of specialty of the examination, of the history of the major complaint(s);
- a description, and disposition, of pertinent “positive” and “negative” detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing;
- results of laboratory and other tests (for example, X-rays) performed according to the requirements stated in the Listing of Impairments (see Part III of this guide);
- the diagnosis and prognosis for the claimant’s impairment(s);
- in claims for adults, a statement about what a claimant can still do despite his or her impairment(s) and whether the claimant has one or more impairment-related limitations or restrictions in the following abilities:
- The ability to perform physical demands of work activities, such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including manipulative or postural functions, such as reaching, handling, stooping, or crouching);
- The ability to perform mental demands of work activities, such as understanding; remembering; maintaining concentration, persistence, or pace; carrying out instructions; or responding appropriately to supervision, co-workers, or work pressures in a work setting;
- The ability to perform other demands of work, such as seeing, hearing, or using other senses; and
- The ability to adapt to environmental conditions, such as temperature extremes or fumes;
- in claims for children under age 18, a statement about the child’s impairment-related limitations and restrictions (as compared to children his or her age who do not have impairments) in:
- acquiring and using information;
- attending and completing tasks;
- interacting and relating with others;
- moving about and manipulating objects;
- caring for yourself; and
- heath and physical well-being; and
- the consultant ‘s consideration, and some explanation or comment on, the claimant’s major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the information provided by the consultant who signs the report.
