Elements of a Consultative Examination (CE) Report for a Disability Based on a Mental Disorder

Elements of a CE Report

General observations

• How the individual came to the examination:
  • Alone or accompanied
  • Distance and mode of transportation
  • If by automobile, who drove
• General appearance
  • Dress
  • Grooming
  • Appearance of invalidism
• Attitude and degree of cooperation
• Posture and gait
• Involuntary movements

Informant

The consultative examiner 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 individual’s allegations concerning any mental or physical problems.

History of Present Illness

• Date and circumstances of onset of the condition
• Date the individual reported that the condition began to interfere with work, and how it interfered
• Date the individual 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 and emotional problems, including:
• Names of treating sources
• Dates of treatment
• Types of treatment (names and dosages of medications, if prescribed)
• Response to treatment
• Hospitalizations for mental disorders, including:
  • Names of hospitals
  • Dates
  • Treatment and response
• Information concerning the individual’s:
  • Activities of daily living
  • Social functioning
  • Ability to complete tasks in timely fashion and appropriately
  • Episodes of decompensation and their resulting effects

Past History

• 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
• History, if any, of substance use and/or treatment in detoxification and rehabilitation centers

Mental Status

• 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

Diagnosis

This should include the American Psychiatric Association standard nomenclature as set forth in the current Diagnostic and Statistical Manual of Mental Disorders, or DSM-V.

Prognosis

Prognosis and recommendations for treatment, if indicated, should be provided. Recommendations for any other medical evaluation (e.g., neurological, general physical) should also be given, if indicated.

Capability Development

Develop capability in every case (initial, reconsideration, continuing disability review when a CE for a mental disorder is being purchased). (Capability refers to an individual’s ability to manage his or her funds.)