Adult Consultative Examination Reports

When an adult Social Security Disability Insurance claimant fails to provide, or provides inadequate, medical information to make a "disability" determination, the Social Security Administration (SSA) will request that a consultative examination (CE) be performed. The claimant's treating physician or an independent medical source may perform the CE. When the CE has been completed, a report must be provided to the SSA that meets the minimum requirements specified by the SSA.

The report must be detailed and thorough, containing a description of the claimant's major complaints along with a history of such complaints. The medical professional should include his findings related to the complaints based on the claimant's history, the examination, and necessary laboratory tests. The SSA mandates that the CE report include the medical professional's diagnosis and prognosis for the claimant's impairment. Further, the medical professional must provide his opinion on the claimant's ability to perform work activities despite his impairment. For physical impairments, this includes an evaluation of the claimant's ability to sit, stand, walk, lift and carry objects, speak, and hear. For mental impairments, the medical profession should opine as to the claimant's ability to understand and remember instructions and respond appropriately to persons in the work place.

In addition to the general criteria for adult CEs, the SSA also mandates the report content for specific impairments. The specific impairments that carry special information requests include those in the areas of internal medicine, rheumatology, orthopedics, respiratory ailments, cardiovascular conditions, neurological conditions, and mental disorders.

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