Michael J. Schulte
Attorney at Law

Pediatric Consultative Examination Reports

A medical professional who has been tapped by the Social Security Administration (SSA) to conduct a consultative examination of a child must include certain information in his report. The SSA mandates that the report containing an assessment of the child's history, examination, and any laboratory findings be consistent with the format for reporting results used for complete internal medicine examinations. The report must be thorough and complete in order to provide the SSA with the necessary information to determine the nature, duration, and severity of the child's impairment as well as the limitations that such impairment places on the child.

A detailed account of the child's history must be included in the report. As children are not capable of providing all the necessary information, the report should include a reference to the individual who does so on their behalf. This is usually a parent or guardian. The historical account should include descriptive statements of the child's present illness including the chief complaints relating to the impairment. Additionally, prior medical conditions and care should be accounted for. The child's growth and development should be discussed along with his social and family history.

The report must contain a complete narrative account of the physical examination of the child from the child's statistics such as height and weight to his general appearance. Further, the SSA has outlined particular issues to be addressed in the report that are geared toward specific impairments such as those involving the musculoskeletal system, senses and speech, respiratory system, cardiovascular system, digestive system, genito-urinary system, hemic and lymphatic systems, skin, endocrine system, neurological systems, multiple body systems, mental disorders, neoplasm, and immune system.

Copyright 2014 LexisNexis, a division of Reed Elsevier Inc.

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This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. Michael J. Schulte
Attorney at Law
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