Social Education » Social Security Disability

Proving You Are Disabled to the Social Security Administration

Admin — Tue, 12 Jan 2010 14:11:41 +0000

We see it too often in our Social Security Disability Law Practice. A potential client will contact us for the first time after their case has been lost before an Administrative Law Judge. When we ask why they did not use a lawyer to try their case the answers we almost always get is “my doctor said I was disabled and even wrote a letter,” or “I thought it was obvious from my records I was disabled”. Other times, we hear “I thought I couldn’t afford a lawyer. “ What these people did not understand, sadly, is that there is nothing obvious about Social Security Disability law. The regulations governing SSD, SSDI and SSI are very complex, even for lawyers who devote their entire practice to this area of the law. Here are some things to keep in mind that will help prove your disability to the Social Security Administration: 1. Hire a lawyer with extensive experience in Social Security Disability law. This seems obvious. . . because it is. Attorney fees in social security disability cases are only paid if you win. The lawyer receives a percentage of the back benefits up to $5,300. 00. The average attorney fees are much less. With the fees being so small compared to what is at stake, why would anyone try to go it alone? For information as to what you should look for in a Social Security disability lawyer. 2. See your doctor regularly, even if you don’t have medical insurance. I know, seeing a doctor can be very expensive, but regular treatment is critical to proving your case. 3. Document your disability impairments, symptoms and limitations with your doctor and be specific. When a doctor writes in his record “Mr. Smith is disabled” it is not very useful. On the other hand, when the doctor writes “Mr. Smith cannot sit or stand for more than 20 minutes at a time because of severe pain” or “Mr. Smith has shortness of breath and chest pain on even minor exertion”, we have much more to talk about with a social security judge. These simple steps will greatly improve your chances of being awarded the social security disability benefits to which you entitled. If you’ve applied for social security disability benefits and haven’t been able to get your disability recognized, it’s not too late to bring a Social Security disability attorney on board now. Your next step will be to file a Request for Reconsideration, which must be filed within 60 days. Since the same committee that made the first decision makes the second, the odds are high that your application will be denied again. In that case, your social security disability law attorney will be able to help you plan a case that will be presented to the Administrative Law Judge. Rather than relying on the previous decisions, the Administrative Law Judge will examine the evidence, listen to the expert opinions of your doctors and psychologists and then make a decision. This is the sole part of the process that you are actually able to speak and be seen by the judge. Sometimes, the judge retains an additional medical expert to review your history and records and offer an opinion, as well as a vocational expert. The vocational expert will assess your employment background, education and skills, and physical limitations, and then make an assessment on your ability to hold a full-time job. The complexity of a social security disability benefits case can not be under-estimated, which is why it’s very important to work with an attorney who specializes in the field.

St. Louis Social Security Disability Lawyer Discusses Tips on Preparing for Your Hearing

Admin — Wed, 23 Dec 2009 14:14:23 +0000

Our office has been working with “Social Security Claimants” for over two decades. Most Social Security applicants don’t understand what is involved in successfully presenting their case in front of an administrative law judge. First, it is important to understand that it is normally not enough to prove that you can’t work at your last job. Instead you must prove that you have a “medically determinable disability” which prevents you from engaging in any “substantial gainful employment”. The word “substantial” is important because you can earn a small amount of wages and still be eligible for disability benefits. The amount is set by the Social Security Administration and can change from time to time. If you are already engaging in substantial employment, then you are not eligible to obtain disability benefits. Secondly, there are regulations which Social security attorneys refer to as “the Grid”. The Social Security Administration recognizes different standards for claimants of different ages, levels of education and work backgrounds. Once the appropriate standards are determined, an attorney can determine whether the medical records are adequate to support the claim for disability. If not, an attorney may pose specific questions to a claimant’s treating doctor(s). Thirdly, it is important for an attorney to help his client quantify his complaints in a specific manner. A claimant may be asked, “How much can you lift”. A bad answer would be “not very much”. An answer like this doesn’t help to describe the claimant’s limitations. It should be noted that Social Security judges refer to something called “The Dictionary of Occupational Titles” for job information. This source describes the exertional requirements of all classified jobs which exist in the national economy. It is up to the claimant’s attorney to prove that his client can’t perform any substantial work for which he is qualified. In addition, “Social Security Judges” will often bring “vocational rehabilitation counselors” into a hearing in order to get clarifications as to the claimant’s “work background”, “work restrictions” and the requirements of various jobs. An attorney must be prepared to effectively challenge the vocational counselor’s testimony through effective cross-examination. Finally, Social Security Hearings are informal and usually take about an hour, although they can vary in length, depending on the judge’s format and the complexity of the case. Your attorney will know the various judges at the “Downtown SSA Office” and the “Creve Coeur SSA Office”. Be sure to dress appropriately, as it is important to create a favorable impression. In short, preparation is the key to winning your case, so talk to your attorney ask him what you can do to help your cause. The contents of this article are intended for educational use only in order to provide readers general information and a basic understanding of the law. If you are seeking legal advice, please consult a licensed professional attorney in your state. The information in this article should not be substituted for experienced legal advice.

What Might Obama do to Social Security Disability?

Admin — Wed, 28 Oct 2009 23:48:18 +0000

Barack Obama addressed close to 250,000 Americans at Grant Park on Tuesday, November 4, 2008 to give his acceptance speech. As a result of winning 364 electoral votes (94 more than the 270 required to win), Obama is the newly-elected president of the United States.

Over the next few months, Obama will tackle the issues he discussed during the heated presidential debates, ranging from the American economy to tax benefits to the war in Iraq. It can be speculated that Senator Obama’s success or failure in reforming America’s Social Security will be one of his most challenging issues as president of the United States in 2008.

At James Madison University on Tuesday, October 28, Obama said, “It won’t be easy… it won’t be quick, but you and I know that it is time to come together and change this country.”

1. Provide Americans with disabilities the educational opportunities they need to succeed:

- Barack Obama supports the Individuals with Disabilities Education Act (IDEA), which would help school districts cover the excess costs of educating children with disabilities. IDEA proposes increasing the current funding by 23%.

2. End discrimination and promote equal opportunity:

- Barack Obama supports Senator Tom Harkin’s ADA Restoration Act, which would redefine the definition of a “disability” in the application of the American with Disabilities Act (ADA). Obama plans to sign this act into law, which would prevent people with epilepsy, diabetes, heart disease, and cancer from being fired from their jobs ‘because they have those conditions.’

- Barack Obama supports universal health care legislation. Under the Obama-Biden plan, people with disabilities who take a job will either continue to receive their current health care or they will be provided a subsidy to purchase health care.

3. Increase the employment rate of workers with disabilities:

-Barack Obama supports the reinstitution of Executive Order No. 13173, which would hire an additional 100,000 federal employees with disabilities within five years. The federal government is the United States’ largest employer, and Barack Obama and Joe Biden support the hiring of employees with disabilities.

- Barack supports the establishment of a National Commission on People with Disabilities, Employment, and Social Security, which would examine the current SSDI, SSI, Medicare, and Medicaid programs in the United States to solve existing problems.

4. Support the independent, community-based living for Americans with disabilities:

- Barack Obama supports Senator Tom Harkin’s Community Choice Act of 2007, which would allow Americans with disabilities the choice of living in communities instead of nursing homes or institutions.

- Obama supports the Fair Home Health Care Act to combat the shortage of community direct care attendants. The Fair Home Health Care Act would increase the wage of health care attendants.

Obama supports a $150 million increase in the Social Security Administration’s (SSA) budget, which he believes has been underfunded. Obama is also committed to improving the application and appeals process for individuals with disabilities to fix the inefficiencies in the current system. Such as:

- Pending hearings have doubled since 2001

- The average weight time for a hearing decision is 505 days, the highest ever in agency history

- The processing times at the hearing level range from 276 days in Charleston to 973 days in Atlanta

- A reconsideration decision can take up to 8 months

What will be the result of an Obama presidency onto Social Security Disability? The question has many Social Security lawyers and Social Security attorneys pondering the issue. With an aging baby boomer generation and a concern that average wait times to receive Social Security Disability benefits are already over two years, most experts will agree that something needs to be done by the next President (Obama) to address the speed at which disability cases are handled.

If you or a family member has been denied disability benefits at the application level, it is advised that you contact a Social Security Disability lawyer. With current wait times of over two years, it is important to remember the sooner you involve a lawyer in the process, the sooner the process can be affected.

By: Matt Berry

How to Build a Social Security Disability Case

Admin — Wed, 07 Oct 2009 03:52:39 +0000

If the evidence provided by the claimant’s own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by re-contacting the treating source for additional information or clarification, or by arranging for a CE. The treating source is the preferred source of purchased examinations when the treating source is qualified, equipped and willing to perform the additional examination or tests for the fee schedule payment and generally furnishes complete and timely reports. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if: The treating source prefers not to perform the examination; there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source; the claimant prefers another source and has a good reason for doing so; or prior experience indicates that the treating source may not be a productive source. The type of examination and/or test (s) purchased depends upon the specific additional evidence needed for adjudication. If an ancillary test (e.g., X-ray, PFS or EKG) will furnish the additional evidence needed for adjudication, the DDS will not request or authorize a more comprehensive examination. If the examination indicates that additional testing may be warranted, the provider must contact the DDS for approval before performing such testing.

Fees for CEs are set by each State and may vary from State to State. Each State agency is responsible for comprehensive oversight management of its CE program.

Selection of a Consultative Examination Source

The DDS purchases consultative examinations only from qualified medical sources. The medical source may be the individual’s own physician or psychologist, or another source. In the case of a child, the medical source may be a pediatrician.

By “qualified,” we mean that the medical source must be currently licensed in the State and have the training and experience to perform the type of examination or test we request. Also, the medical source must not be barred from participation in our programs. The medical source must also have the equipment required to provide an adequate assessment and record of the existence and level of severity of the individual’s alleged impairments.

Medical professionals who perform CEs must have a good understanding of SSA’s disability programs and their evidence requirements. The physician or psychologist chosen may use support staff to help perform the consultative examination. Any such support staff (e.g., X-ray technician, nurse, etc.) must meet appropriate licensing or certification requirements of the State.

Generally, sources are selected based on appointment availability, distance from a claimant’s home and ability to perform specific examinations and tests.

Consultative Examination Report Content

The examination report should include the claimant’s claim number and a physical description of the claimant, to help ensure that the person being examined is the claimant.

The detail and format for reporting the results of the medical history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete medical examination.

The report should be complete enough to enable an independent reviewer to determine the nature, severity and duration of the impairment, and, in adults, the claimant’s ability to perform basic work-related functions. The history and physical examination must be provided as a narrative of the findings.

Conclusions in the report must be consistent with the objective clinical findings found on examination and the claimant’s symptoms, laboratory studies, and demonstrated response to treatment and on all available information, including the history. The report, for adults, should include a description, based on the provider’s own findings, of the individual’s ability to do basic work-related activities. It should not include an opinion as to whether the claimant is disabled under the meaning of the law.

Signature Requirements

All CE reports must be personally reviewed and signed by the provider who actually performed the examination. The provider doing the examination or testing is solely responsible for the report contents and for the conclusions, explanations or comments provided. The source’s signature on a report annotated “not proofed” or “dictated but not read” is not acceptable. A rubber stamp signature or signature entered by another person, such as a nurse or secretary, is not acceptable.

How the DDS Reviews Consultative Examination Reports

The DDS is obligated to review the report of the CE to determine whether the specific information requested has been furnished.

The CE report must:

Provide evidence that serves as an adequate basis for disability decision making in terms of the impairment it assesses.

Be internally consistent. Are all the diseases, impairments and complaints described in the history adequately assessed and reported in the clinical findings?

Do the conclusions correlate the medical history, the clinical examination and laboratory tests, and explain all abnormalities?

Be consistent with the other information available within the specialty of the examination requested.

Did the report fail to mention an important or relevant complaint within that specialty that is noted in other evidence in the file (e.g., blindness in one eye, amputations, pain, alcoholism, depression)?

Be adequate as compared to the standards set out in the course of a medical education.

Be properly signed.

If the report is inadequate or incomplete, the DDS will contact the provider and ask the provider to furnish the missing information or prepare a revised report.

Elements of a Complete Consultative Examination

A complete CE is one that involves all the elements of a standard examination in the applicable medical specialty. When the report of a complete CE is involved, the report should include the following elements:

The claimant’s major or chief complaint(s);

Detailed description, within the area of specialty of the examination, of the history of the major complaint(s);

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 (e.g., X-rays) performed in accordance with the requirements provided by the DDS.

Diagnosis and prognosis for the claimant’s impairment(s);

Statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should describe the opinion of the consulting physician or psychologist about the claimant’s ability, despite his or her impairment(s), to do work-related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; and, in cases of mental impairment(s), the opinion of the physician or psychologist about the individual’s ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting; and

The consultative physician or psychologist will consider, and provide 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 physician or psychologist who signs the report.

Report Content by Specific Impairment

Internal Medicine

The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete internal medical examination.

Source of History

The physician should indicate from whom the history was obtained and should provide an estimate of the reliability of the history.

History of Present Illness

The chief complaint(s) alleged as the reason for not working should be discussed in detail, including:

Factors which increase the problem or impairment(s);

How long the problem has been present;

Factors which may provide relief; and

The claimant’s description of how the impairment(s) limits the ability to function.

Pertinent descriptive statements by the claimant, such as a description of chest pain, should be recorded in the claimant’s own words.

The information must be in a narrative, rather than “questionnaire” or “check-off” format.

Past History should describe other prior illnesses, injuries, operations, or hospitalizations and give the dates of these events.

Current Medication should be listed by name of drug and dose.

Review of Systems should describe and discuss:

Other complaints and symptoms the claimant has experienced relative to the specific organ systems, and

The pertinent negative findings, which would be considered in making a differential diagnosis of the current illness or in evaluating the severity of the impairment.

Social History should include pertinent findings about use of tobacco products, alcohol, nonprescription drugs, etc.

Family History should be presented, if pertinent.

Signs

The vital signs should include:

Blood pressure;

Pulse rate;

Respiratory rate; and

Height and weight without shoes.

The physical examination must provide a description of the claimant’s general appearance and pertinent behavior during the examination (e.g., for back complaint, how the claimant stood or walked, got up from a chair, and got on and off the examination table).

This description must be in narrative, rather than “questionnaire” or “check-off” form.

The report should present aspects of the examination dealing with the claimant’s major and minor complaints in particular detail, describing both pertinent negative and positive findings.

Pelvic examinations should not be performed unless specifically authorized.

Specific range of motion of a joint should be reported in degrees for joints in which there is a significant limitation of motion.

NOTE: If a joint is found to have no abnormality of range of motion on gross examination, that fact should be stated rather than reporting the degree of motion.

Laboratory Tests — The laboratory should provide:

Actual values for laboratory tests; and

Normal ranges of values in either the medical report or attached laboratory report.

Electrocardiographic and Spirographic Reports

Tracings must be provided when these tests have been performed.

The reported findings for pulmonary and electrocardiographic studies must meet the requirements of Section 3.00E and 4.00C, respectively, of the Listing of Impairments.

Interpretation

The interpretation of laboratory tests (e.g., electrocardiographic tracings) must take into account and be correlated with the history and physical examination findings.

Identify the physician providing the formal interpretation of the laboratory tests, when other than the physician who is signing the CE report.

If the interpretation is provided separately, the report sheet should state the interpreting physician’s name and address.

X-rays

Joints and other areas to be x-rayed are those that are specifically requested or those that the physical examination reveals to be the most involved by disease, after appropriate authorization by the DDS.

Rheumatology

In addition to the requirements for a general internal medical examination, the following specific information should be stated in a report of an examination in which the primary complaint is a rheumatological disorder.

General Observations

General observations in the physical examination should relate to common, everyday functions which may be observed in the examining physician’s office, such as:

Stance;

Gait;

Ability to:

Dress and undress;

Climb upon the examining table;

Grasp or shake hands; and

Write.

Joint Examination

Joint examination should include specific, detailed notations with respect to the presence or absence of:

Effusion;

Episodes of infection;

Periarticular swelling;

Tenderness;

Heat;

Redness;

Thickening of the joints;

Specific range of motion of the joints and back in degrees; and

Structural deformities.

Specific range of motion of a joint or spine should be reported in degrees for any joint or spine in which there is a significant limitation of motion.

If the range of motion is found to be restricted in any joint or spine, annotation should be made as to probable cause (e.g., due to pain and/or influenced by observable abnormality).

Joints/spine to be x-rayed are those that are specifically requested or those that the physical examination reveals to be the most involved by disease, after appropriate authorization by DDS.

For individuals alleging myalgias or other muscular complaints, evaluate the areas of muscle tenderness including tender points and trigger points. Go to Listing of Impairments – Adults: Immune System 14.00 for more information.

Orthopedic

History

The orthopedic examination, including the lumbar and cervical spine, should describe and discuss (where appropriate):

The major or chief complaint(s) alleged as the reason for not working. The discussion of the complaints must include:

A detailed historical description of the pertinent past history of the disease.

The claimant’s statement of current complaint.

Current and past therapy for this disorder, and response to therapy, should be reported. Hospitalizations, surgical operations, and significant investigative procedures (e.g., myelography, CAT scan, MRI, Bone Scan) should be reported with the dates of the hospitalizations and result of the procedures.

The symptoms alleged, including a description of:

The character, location, and radiation of pain;

Mechanical factors which incite and relieve the pain;

Prescribed treatment, including name, dose, and frequency of any medications which are used;

The claimant’s typical daily activities; and

Symptoms of weakness, other motor loss, or any sensory abnormalities.

The use of drugs or alcohol.

Other significant past illnesses, injuries, operations, particularly those involving the musculoskeletal system.

From whom the history was obtained and an estimate of the reliability of the history.

Physical Examination — The physical examination report should include a description and discussion (where appropriate) of:

The claimant’s general appearance and nutrition, any apparent skeletal or other musculoskeletal abnormalities.

The orthopedic and neurological findings. These should include a description of:

Muscle spasms, limitation of movement of the spine given quantitatively in degrees from the vertical position when there is significant limitation in motion, straight leg raising given quantitatively in degrees from the supine position and from the sitting position, motor and sensory abnormalities, and deep tendon reflexes. Deep tendon reflexes should be described as to intensity and symmetry.

If there is no abnormality of range of motion of any affected joint on gross examination, that fact, rather than the actual degree of motion, may be reported.

Motor function quantitated. The method of quantitation must be reported. The most widely used method involves recording from 0 to 5 as a fraction with the numerator representing the claimant’s performance and the denominator representing a normal performance (e.g., 3/5).

To what degree motor function is inhibited by spasticity, rigidity or pain.

The specific distribution of sensory deficit or pain.

Muscle bulk. When there is asymmetry, specific measurement must be reported.

Atrophy must be reported in terms of circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters.

A specific description of atrophy of hand muscles may be given without measurements of atrophy but should include measurements of grip strength.

Gait and station, including the claimant’s ability to:

Tandem walk;

Walk on heels and toes;

Hop;

Bend;

Squat;

Arise from a squatting position;

Dress and undress;

Get up from a chair;

Get on the examining table; and

Cooperate during the examination.

Laboratory Tests — X-rays or other laboratory tests

The physician providing the formal interpretation must be identified.

If the interpretation is provided on a separate report form, that report should be attached.

Findings

The physician’s examination findings must be determined on the basis of the physician’s observations during the examination. (Alternative testing methods should be used to verify the objectivity of the abnormal findings, when possible; e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test.) Go to Listing of Impairments – Adults: Musculoskeletal System 1.00 for more information.

Respiratory

In addition to the requirements for a general internal medical examination, the specific information listed below should be stated in a report of an examination in which the primary complaint is a respiratory disorder.

General Examination

The report should note and describe:

The occurrence of cough, labored breathing, use of accessory muscles of respiration, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the presence of chest wall deformity. Respiratory rate should be observed and reported.

The diameter of the chest on inspiration and expiration, distention of neck veins and ankle edema.

Whether the expiratory phase of respiration is prolonged.

Breath sounds.

Diaphragmatic motion.

Presence or absence of adventitious sounds on auscultation of the chest.

The employment history, when relevant to the disease, should be reported (e.g., pneumoconiosis or exposure to physical irritants producing respiratory symptoms.)

Dyspnea

Characteristics — Dyspnea should be described with respect to:

Dates and mode of onset;

Seasonal influence;

Influence of infection and precipitating activities;

Whether it is associated with palpitation, wheezing, chest discomfort, or hyperventilation symptoms.

Respiratory Versus Cardiac Dyspnea — Inquiry should be made to determine whether the claimant has:

A history of heart disease;

Experienced paroxysmal nocturnal dyspnea or orthopnea; and

Associated peripheral edema, hypertension, past myocardial infarction, angina, rheumatic heart disease, cardiac murmur, etc.

Episodic Disorders — The report should include details as to:

Onset and precipitating factors;

Frequency and intensity;

Duration;

Mode of treatment and response; and

Description of severe respiratory attack.

Ancillary Studies

Chest X-ray, Spirometry, Diffusing Capacity of the lungs for Carbon Monoxide, and Arterial Blood Gas Studies will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process. Go to Listing of Impairments -Adults: Respiratory System 3.00 for more information.

Cardiovascular

In addition to the requirements for a general internal medical examination, the following specific information should be stated in a report of an examination in which the primary complaint is a cardiovascular disorder.

General Examination — The report must:

Provide a detailed description of the examination of the heart, including the heart sounds and rhythm and pulses.

Describe:

Any jugular vein distention, including angle of reclining at which distention occurs;

Adventitious lung sounds;

Hepatomegaly;

Peripheral or pulmonary edema; and

Cyanosis.

Describe the impact of the chest discomfort, dyspnea or other cardiovascular symptoms on physical activities.

Describe any drugs used (currently and in the recent past) for treatment of the cardiovascular disorder and indicate the dosage and the response to these drugs.

Note participation in a cardiac rehabilitation program (e.g., progressive physical activity, educational or psychological support).

Congestive Heart Failure — The history must include a discussion of:

The known factors in the development of the cardiac condition (e.g., myocardial infarction, rheumatic heart disease, hypertension, and congenital or other organic heart disease).

Recurrent or persistent symptoms such as:

Fatigue;

Dyspnea;

Orthopnea; and

Anginal discomfort.

Chest Discomfort and Other Symptoms — The report should describe:

Chest discomfort of myocardial ischemic origin or other symptom(s) in the claimant’s own words with respect to:

Presence;

Character;

Location;

Radiation;

Frequency;

Duration;

Usual inciting factors; and

Relief.

The historical character of the chest discomfort to ascertain whether:

There is a predictable stable pattern of occurrence; and

There is evidence of a recent change in the pattern of symptoms;

Whether therapy has been prescribed and how the claimant is responding to the therapy;

Whether the discomfort occurs at rest or awakens the claimant from sleep and whether it is related to ingestion of food or movement of the upper extremities; and

The usual duration of the symptoms, especially chest discomfort, how symptoms are relieved, and the time required to obtain relief (e.g., rest or after taking specific drugs such as nitroglycerin).

Laboratory Tests

Ancillary cardiac testing, such as ECG, Exercise Stress Testing and Echocardiogram, will be requested in accordance with program criteria for the purpose of establishing the existence and extent of the disease process. Go to Listing of Impairments – Adults: Cardiovascular System 4.00 for more information.

Neurological

Historical Source

The DDS will make arrangements to have a knowledgeable individual accompany the claimant to the examination, when prior information indicates incompetence on the part of the claimant.

The physician should indicate from whom the history was obtained and should estimate reliability of history.

History — The history should include a detailed description/discussion of:

Major or chief complaints with:

Detailed historical description of the disease state; and

Current complaints.

The mental or physical functional restrictions with specific examples.

Significant illness, injuries, or operations, particularly of the nervous system.

Current and past therapy for the disorder alleged, and any abuse or drugs or alcohol.

The family history with information on pertinent positive abnormalities, particularly hereditary familial conditions.

Physical Examination

General — The physical examination should provide a statement concerning the claimant’s:

General appearance;

Nutrition;

Body habitus;

Head size and shape;

Any skeletal or other abnormalities such as pigmentary or texture changes of the skin or changes in hair distribution; and

Dominant hand

The gait and station must be described in detail, including ability to:

Tandem walk;

Walk on heels and toes;

Hop;

Dress and undress;

Get up from a chair;

Get on the examining table; and

Generally cooperate during the examination.

Notation should be made of the function of the 12 cranial nerves (if the first cranial nerve is not tested, this should be noted). Lower cranial nerve function should be described in particular detail when dysphagia or dysarthria is a complaint.

Ocular motility and pupillary size and activity should be described even when normal. The visual acuity and visual fields by gross confrontation should be estimated, and the basis for the estimate must be stated.

Motor function — Should be quantitated, and the method of quantitation reported. For example, if a numbering system is used, the report must state which number represents normal strength and which number represents total paralysis.

The report must also describe to what degree motor function is inhibited by spasticity, rigidity, involuntary movements, or tremor.

Muscle bulk should be described, and when there is asymmetry, measurements should be reported.

The degree of fatigability following rapid, repetitive movements should be noted.

All modalities of sensation, including cortical, should be tested.

The method of testing should be recorded.

When sensory deficit or pain are described in a specific distribution, care should be taken to ascertain that the findings are consistent with neuroanatomical fact. Suspected non-physiological observations should be noted.

Coordination should be tested.

The ability to perform fine and dexterous movements of the hands should be described.

In-coordination or tremor at rest or during specific tests should be described in detail and quantitated.

NOTE: Examples should be given describing the functional loss that occurs because of these events.

Reflexes

Deep tendon reflexes should be described as to intensity and symmetry.

Superficial reflexes should be described when present and noted when absent.

Any pathological reflexes must be described in detail.

Any impairment of speech or language should be described in detail with a discussion of how much ability the claimant retains and how the physician determined this. The report should discuss:

Aphasia;

Dysarthria;

Stuttering (fluency);

Involuntary vocalizations;

Whether speech is intelligible.

Mental Status Examination — should be reported and be extensive when mental capacity is in question. The physician should provide:

Examples of responses in testing orientation, memory, calculation, insight, general understanding, and fund of knowledge; and

A detailed description of mood and behavior during the examination, and any significant abnormalities. Go to Listing of Impairments – Adult: Neurological 11.00 for more information.

Mental Disorders

The psychiatric or psychological examination report should show not only the claimant’s signs, symptoms, laboratory findings (psychological test results), and diagnosis, but also describe the effect of the emotional or mental disorder on the claimant’s ability to function at the usual and customary level of adjustment — personal, social and occupational.

General Observations — Include in the CE report general observations of:

How the claimant came to the examination:

Alone or accompanied;

Distance and mode of transportation; and

If by automobile, who drove.

General appearance:

Dress; and

Grooming

Attitude and degree of cooperation.

Posture and gait.

General motor behavior, including any involuntary movements.

Informant

The psychiatrist or psychologist should identify the person providing the history (usually the claimant) and should provide an estimate of the reliability of the history.

Chief Complaint

This usually will consist of the claimant’s allegations concerning any mental and/or physical problems.

History of Present Illness

This should include a detailed chronological account of the onset and progression of the claimant’s current mental/emotional condition with special reference to:

Date and circumstances of onset of the condition;

Date the claimant reported that the condition began to interfere with work, and how it interfered;

Date the claimant reported inability to work because of the condition and the circumstances;

Attempts to return to work and the results;

Outpatient evaluations and treatment for mental/emotional problems including:

Names of treating sources;

Dates of treatment;

Types of treatment (names and dosages of medications, if prescribed); and

Response to treatment.

Hospitalizations for mental disorders including:

Names of hospitals;

Dates; and

Treatment and response.

Information concerning the claimant’s:

Activities of daily living;

Social functioning;

Ability to complete tasks timely and appropriately; and

Episodes of decompensation and their resulting effects.

Past History should include a longitudinal account of the claimant’s personal life including:

Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment;

Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional problems; and

History, if any, of substance abuse, and/or treatment in detoxification and rehabilitation centers.

Mental Status

The individual case facts will determine the specific areas of mental status that need to be emphasized during the examination, but generally the report should include a detailed description of the claimant’s:

Appearance, behavior, and speech (if not already described);

Thought process (e.g., loosening of associations);

Thought content (e.g., delusions);

Perceptual abnormalities (e.g., hallucinations);

Mood and affect (e.g., depression, mania);

Sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information, and intelligence);

Judgment and insight; and

Capability (i.e., is the individual capable of handling awarded benefits responsibly?)

Diagnosis

American Psychiatric Association standard nomenclature as set forth in the current “Diagnostic and Statistical Manual of Mental Disorders.”

Prognosis

Prognosis and recommendations for treatment, if indicated; also, recommendations for any other medical evaluation (e.g., neurological, general physical), if indicated.

Additional Requirements by Mental Disorder

Schizophrenic, Delusional (Paranoid) Schizo-Affective, and other Psychotic Disorders — The report should reflect:

Periods of residence in structured settings such as half-way houses and group homes;

Frequency and duration of episodes of illness and periods of remission; and

Side effects of medications.

Organic Mental Disorders — The report should reflect:

The source of the disorder, if known, the prognosis; and

Whether there is an acute or chronic process;

Whether stable or progressive; and

Changes at various points in time.

The results of any psychological or neuropsychological testing that could serve to further document an organic process and its severity.

Information regarding the results of any neurological evaluations.

Information about any neurological testing (e.g., EEG, CT scan) that may have been performed and the results, if available.

In Mental Retardation cases, the report should reflect:

Current documentation of IQ by a standardized, well-recognized measure. Acceptable instruments will have a representative normative sample, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions (e.g., the Wechsler scales);

Verbal IQ, performance IQ, and full scale IQ scores, together with the individual subtest scores;

Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that may have influenced the results such as the claimant’s attitude and degree of cooperation, the presence of visual, hearing or other physical problems, and recent prior exposure to the same or similar test; and

Consistency of the obtained test results with the claimant’s education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.

By: Greeman & Toomey