Nursing Diagnosis Impaired Memory
How to build a case for Social Security disability,
If the evidence provided by the applicant's own medical sources is insufficient to determine if he or she is disabled, additional medical information may be requested to return to contact the treating source for additional information or clarification, or by arranging a CE. The source is the treatment of purchased examinations preferred source of treatment when the source is qualified, equipped and prepared to evidence or further evidence to the fee schedule for payment and in general provides complete and timely reports. Even if only one additional test is required, treatment the source is usually the preferred source for this service. SSA rules for the use of providing an independent source (other than the treating source) for a diagnostic study EC or if: The source of deal rather not take the exam, there are conflicts or inconsistencies in the file can not be resolved by returning to the source of treatment, the claimant prefers another source and have a good reason to do so, or previous experience indicates that treatment of the source can not be a productive source. type of examination and / or test (s) purchased depends on the specific evidence necessary for adjudication. If, for example an ancillary test (X-ray, SLP or EKG), will provide additional evidence needed for adjudication, DDS does not request or authorize a more thorough examination. If the review indicates that additional testing may be justified, the provider should contact the DDS for approval before these tests.
Fees for CEs are set by each state and vary from state to state. Each state agency is responsible for comprehensive oversight management of its CE program.
Selecting a Source-examination
DDS consultation purchases only reviews qualified medical sources. The medical source may be your own person's physician or psychologist, or other source. In the case of a child, the medical source may be pediatrician.
By "qualified", we mean that the medical source must be currently licensed in the state and have the training and experience to do the type of exam or test requested. In addition, the medical source must not be excluded from participation in our programs. The medical source must also have the equipment necessary to provide adequate assessment and record of the existence and severity of the alleged alterations of the individual.
Medical professionals who perform CEs must have a good understanding of disability programs of the SSA and the requirements of their statements. The physician or psychologist may use the personal choice support to help with the consultative review. Any such support staff (eg X-ray technician, nurse, etc.) must meet appropriate licensure or requirements State certification.
In general, the sources are selected based on appointment availability, distance from home of the complainant and the ability to perform examination and testing.
Test Content Advisory Report
The investigation report must include the claim number concerned and a physical description of the applicant, to help ensure that the person examined is the applicant.
The detail and format for reporting results Medical history, physical examination, laboratory findings and discussion of the conclusions should follow the principles of standard reporting a complete medical examination.
The report should be complete enough to allow an independent reviewer to determine the nature, severity and duration of alteration, and in adults, the applicant's ability to perform basic functions related to the job. The history and physical examination should include as a narrative of the findings.
Conclusions in the report should be consistent with objective clinical findings found in the exploration and symptoms of the claimant, laboratory studies, and showed response to treatment and all available information, including the history. The report, for adults, should include a description based on the provider's own findings, the individual's ability to do basic activities related to the job. It should not include an opinion whether the applicant is disabled under the meaning of the law.
Signature Requirements
All reports must be personally reviewed CE and signed by the provider who actually performed the test. The supplier to the exam or test is solely responsible for the content of the report and the conclusions, explanations or comments provided. The signature of the source in a report noted "no evidence" or "dictated but not read" is not acceptable. A signature stamp or signature entered by another person, such as a nurse or a secretary is not acceptable.
How does the DDS Advisory Opinions Examination Report
The DDS is required to review the report of the EC to determine whether the specific information requested has been submitted.
The EC report must:
Provide evidence that serves as a basis for decision-making disabilities in terms of impairment it assesses.
Be internally consistent. Are all diseases, impairments and complaints described in history to properly evaluate and reported in the clinical findings?
Do the conclusions correlate the clinical history, clinical examination and laboratory tests, and explain all the anomalies?
Be consistent the information available within the specialty of the examination requested.
Does the report fail to mention a major complaint or reference this specialty that observed in other archival documents (eg, blindness in one eye, amputations, pain, alcoholism, depression)?
Be adequate in comparison with the standards set in the context of medical education.
Properly signed.
If the report is inadequate or incomplete, the DDS will contact the supplier and have the supplier provide the missing information or prepare a revised report.
Elements of a comprehensive review Advisory
A complete CE is one that involves all elements of a placement test in the medical specialty applicable. When the report of a complete CE is involved, the report shall include the following elements:
the main claimant's chief complaints or (S)
Detailed description in the specialty area examination of the history of chief complaint (s)
Description, and disposition, of pertinent "positive" and "negative" detailed findings based on history, examination and related laboratory tests with the chief complaint (s) and any other abnormalities or lack thereof reported or the evidence found during examination or laboratory;
Laboratory results and other tests (eg X rays) carried out in accordance with the requirements prescribed by the DDS.
Diagnosis and prognosis of the claimant's failure (S)
Statement on what the claimant can still do despite your impairment (s), unless the claim is based on legal blindness. This statement should describe the opinion of the medical officer or psychologist about the claimant's ability, despite his impairment (s) to perform activities related to work such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling, and in cases of mental impairment (s), doctor's opinion or psychologist about the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers and pressures working in a work environment and
The consulting physician or psychologist shall take into account, and give some explanation or comment on, the main complaints of the claimant (s) and any other abnormalities found during the history and examination or reported from laboratory tests. The history, examination, assessment of laboratory test results, and conclusions contain the information provided by the physician
or psychologist who signs the report.
Report Content specific disability
Internal Medicine
The detail and format for presenting the results of history, physical examination, laboratory findings and discussion of the conclusions should follow the standard reporting principles for a complete medical examination procedure.
Source of History
The physician must indicate from which history was obtained and should provide an estimate of the reliability of history.
History of present illness
The main complaint (s) alleged as the reason for not working should be discussed in detail, including:
Factors that increase the problem or impairment (s)
How long the problem has been present;
Among the factors that can provide relief and
The claimant's description of how the impairment (s) limits the ability to function.
Relevant descriptive statements the claimant, for example, description of chest pain should be recorded in the words of the complainant.
The information should be in a narrative instead of "guest" or "check-off format.
Past history should describe any other previous illnesses, injuries, operations or hospitalizations and give the dates of these events.
Current Medications must be listed by drug name and dosage.
Review of systems should describe and discuss:
Other complaints and symptoms that the plaintiff has suffered in relation to specific organs and systems, and
Negative results relevant to consider to make a difference current disease diagnosis or in assessing the severity of the disturbance.
Social History should include relevant findings on the use of snuff products, alcohol, prescription medicines, etc.
Family history should be presented, where relevant.
Signs
The vital signs should include:
Blood pressure;
Pulse
Respiratory rate and
Height and weight without shoes.
The physical examination should provide a description of the claimant's general appearance and relevant conduct during the examination (eg, subsequent claim, the claimant standing or walking, he rose from his chair and got on and off the examination table.)
This description should be in narrative, rather than "guest" or "check-off form.
The report should present the issues review any complaints of major and minor claimant in particular detail, describing both the positive and negative conclusions relevant.
Pelvic exams should not be made without express authorization.
specific range of motion of a joint should be expressed in degrees for joints in which is a significant limitation of motion.
NOTE: If a joint is found to have no anomaly in the range of motion in the macroscopic examination, that fact should be stated instead of reporting the degree of movement.
Laboratory Tests – The laboratory must provide:
The actual values laboratory tests;
Normal ranges of values in either the physician or laboratory report attached report.
Electrocardiographic and spirographic Information
Strokes should be made clear whether these tests have been performed.
The results reported for electrocardiographic studies pulmonary and must meet the requirements of Section 3.00E and 4.00C, respectively, from the sale of Impairments.
Interpretation
Interpretation laboratory tests (eg, electrocardiographic tracings) should take into account and be related to the history and physical examination.
Identify physician provide the formal interpretation of laboratory tests when your doctor is not signing the report of the EC.
If the interpretation is separately sheet must indicate the medical report of the name and address interpretation.
X-rays
Joints and other areas to be an X-ray are those who specifically requested or physical examination revealed to be the most affected by the disease, after due approval by the DDS.
Rheumatology
In addition to the requirements for a general medical examination, at home, the following specific information must be expressed a report of a test in which the main complaint is a rheumatic disorder.
General Observations
General observations on physical examination refer to common everyday functions that can be seen from the medical examiner's office, such as:
Attitude;
March;
Ability to:
Dress and undress
Get on the stretcher;
Grab or shake hands, and
Write.
Joint Review
joint review should include specific entries, detailed with respect to the presence or absence of:
Stroke;
Episodes of infection;
Periarticular swelling;
Sensitivity;
Heat;
Redness;
Thickening of the joints;
specific range of motion of joints and back in degrees, and
structural deformities.
Specific range of motion of a joint or the spine must be expressed in degrees for any joint or spine in which there is a significant limitation of motion.
If the range of movement is to restrict in any joint or spine, annotation must be done to determine the probable cause (for example, due to pain and / or influenced by observable anomaly.)
Joints / column to be an X-ray are those who specifically requested or physical examination revealed as the most affected by the disease, after due approval by the DDS.
For persons claiming myalgia or other muscle discomfort, assess the areas of muscle tenderness, including tender points and trigger points. Go to the List of Adult Impairments – 14.00 Immune System for more information.
Orthopedic
History
The orthopedic examination, including the lumbar and cervical spine, they should describe and discuss (if any):
The principal or chief complaint (s) alleged as the reason for not working. The discussion of complaints should include:
A detailed historical description of relevant past history of the disease.
The claimant statement of the current complaint.
Current therapy and the history of this disorder, and response to therapy should be informed. Hospitalizations, surgeries, and important research procedures (eg, myelography, CT, MRI, bone scan) should be reported with dates of hospitalizations and the outcome of the proceedings.
The alleged symptoms, including a description of:
The nature, location, and radiation of pain;
Mechanical factors which incite and relieve pain;
prescribed treatment, including name, dosage and frequency of used drugs;
The claimant typical daily activities,
Symptoms of weakness, loss of motor, or any sensory disturbances.
The use of drugs or alcohol.
Other previous major diseases, injuries, operations, in particular on the musculoskeletal system.
Whose history was obtained and an estimate of the reliability of history.
Physical Exam – The physical examination report must include a description and discussion (if applicable):
The general appearance of the claimant and nutrition, any Musculoskeletal apparent anomaly or other skeletal.
The orthopedic and neurological disorders. These should include a description From
Muscle spasms, limitation of movement of the spine given quantitatively in degrees from the vertical position when there is limitation significant movement, straight leg raising given quantitatively in degrees from the supine and sitting position, motor and sensory disturbances and reflections Deep tendon. Deep tendon reflexes should be described as the intensity and symmetry.
If there is abnormality of the range of motion any affected joint on gross examination, that fact, rathe
r than the actual degree of movement may be reported.
Motor function quantified. The method of quantification must be reported. The most widely used is the 0-5 record as a fraction with the numerator corresponds to the capacity the claimant and the denominator representing normal performance (eg 3 / 5).
To what degree motor function is inhibited by spasticity, stiffness or pain.
The specific distribution of sensory deficit or pain.
Muscle mass. When there is an asymmetry, specific measurement must be reported.
Atrophy should be reported in terms of measurements of the circumference of both thighs and calves (or top or bottom of the arms) a point made above and below the knee or elbow in inches or centimeters.
A specific description of the atrophy of muscles hand can be given without measures of atrophy but should include measurements of grip strength.
Gait and station, including the claimant's ability to:
Tandem walk;
Walking on heels and toes;
Hop;
Double;
Squat;
Arise from a squatting position;
Dressing and undressing;
Rising from a chair;
Get on the couch and
Cooperate during the test.
Laboratory Tests – X-rays or other lab tests
The doctor who delivers the training interpretation should be identified.
If the interpretation is always a way to separate report, the report shall be attached.
Assessment
The medical examination results will be determined on the basis of observations by the doctor during the exam. (Alternative test should be used to verify the objectivity of the abnormal results, where possible, for example, a sitting straight leg raising test in addition to a supine leg raising test.) Go to the List of Adult Disabilities – Musculoskeletal System 1.00 for more information.
Respiratory
In addition to the requirements for a general medical examination, internally, the specific information listed below shows a report of an examination in which the main complaint is a respiratory disorder.
General Review
The report should identify and describe:
The appearance cough, difficulty breathing, use of accessory muscles of respiration, audible wheezing, paleness, cyanosis, hoarseness, clubbing of fingers, or the presence of deformity chest wall. The respiratory rate should be observed and reported.
The diameter of the chest in inspiration and expiration, detente of neck veins and ankle edema.
If the expiratory phase of respiration is prolonged.
Breath sounds.
Diaphragmatic movement.
The presence or absence of strange noises on auscultation of the chest.
The employment history, when relevant to the disease, should be reported (eg, pneumoconiosis or exposure to physical irritants cause respiratory symptoms.)
Dyspnoea
Features – Dyspnea should be described with respect to:
Dates and start mode;
seasonal influence;
Influence of infection and precipitating activities;
Whether that is associated with palpitations, wheezing, chest discomfort or symptoms of hyperventilation.
Respiratory Dyspnea Versus Heart – should be investigated 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 pectoris, rheumatic heart disease, bruit, etc.
Episodic Disorders – The report should include details of:
Start and precipitating factors;
The frequency and intensity;
Duration;
Mode of treatment and response, and
Description severe respiratory attack.
Additional studies
The chest radiograph, spirometry, diffusing capacity of lungs for carbon monoxide and arterial blood gas studies were requested according to the program criteria in order to establish the existence and extent of disease process. Go to Listing of Impairments-Adults: Respiratory System 3.00 for more information.
Cardiovascular
In addition to the requirements for a general medical examination, at home, the following specific information must be stated in a report of a test in which the main complaint is a cardiovascular disorder.
General Review – The report must:
Provide a detailed description of the examination of the heart, the heart sounds and rhythm and pulses.
Describe:
Any relaxation of the jugular vein, including angle rest in which the relaxation occurs;
adventitious lung sounds;
Hepatomegaly;
Peripheral or pulmonary edema, and
Cyanosis.
Describe the impact of chest discomfort, dyspnea or other cardiovascular symptoms in physical activities.
Describe the drugs used (currently and in the recent past) for the treatment of cardiovascular disease and indicate the dose response of these drugs.
Consider participation in a cardiac rehabilitation program (eg, progressive physical activity, education or psychological support).
Congestive Heart Failure – The history should include discussion of:
Known factors in the development of heart disease (eg myocardial infarction, rheumatic heart disease, hypertension and congenital heart disease or other organic).
symptoms recurrent or persistent, such as:
Fatigue;
Dyspnea
Orthopnea, and
bothered by angina.
Chest discomfort and other symptoms – The report should describe:
Chest discomfort of myocardial ischemic origin or any other symptom (s) in the words of the claimant with respect to:
Presence;
Character;
Location;
Radiation;
Frequency;
Duration;
Usual inciting factors, and
Socorro.
The historical character of chest discomfort to determine whether:
There is a stable, predictable pattern of occurrence, and
There is evidence of a recent change in the pattern of symptoms;
If therapy has been prescribed and the claimant is responding to therapy;
If discomfort occurs at rest or awake, the plaintiff may sleep and if it is related to the ingestion of food or the movement of the upper extremities, and
The usual duration of symptoms, especially chest discomfort, how relieved the symptoms and the time required to obtain a measure (eg, rest or after taking specific drugs, such as nitroglycerin).
Laboratory Tests
Assistant heart tests such as ECG, exercise stress test and echocardiogram, is requested under the program criteria in order to establish the existence and extent of the disease process. Go to the List of Adult Disabilities – Cardiovascular System 4.00 for more information.
Neurological
Historical Source
The DDS will arrange for an individual accompany the applicant knows consideration, as the preliminary information indicates incompetence on the part of the claimant.
The physician should indicate from the which history was obtained and must estimate the reliability of history.
History – The history should include a detailed description / analysis:
Mayor or reasons for consultation with:
Detailed historical description of the disease state, and
current complaints.
Restrictions physical or mental functional with specific examples.
major diseases, injuries or operations, including the nervous system.
Therapy Current and past for the alleged disorder, and any abuse or drugs or alcohol.
The history of the family with relevant information on positive anomalies, particularly family hereditary conditions.
Physical Exam
General – The physical examination should include a statement of the claimant: <
/p>
General appearance;
Nutrition;
body habitus;
Head size and shape;
Any skeletal abnormalities or other such as pigmentation or skin texture changes or changes in hair distribution, and
Dominant hand
Walking and the station must be described in detail, including the ability to:
Tandem walk;
Walking on heels and toes;
Hop;
Dress and undress
Rising from a chair;
Get on the couch and
In general, cooperate during the examination.
Notation should be made of the role of the 12 cranial nerves (cranial nerves if the first 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 pupil size and activity should be described, even when normal. Acuity visual and visual fields by confrontation gross must be estimated, and the basis for the estimate must be stated.
Motor function – Should be quantified, and the method of quantification reported. For example, if a numbering system is used, the report should indicate what number represents the strength normal and what number represents a total paralysis.
The report should also describe what degree motor function is inhibited by spasticity, rigidity, involuntary movements or tremor.
muscle mass should be described, and when there is asymmetry, the measurements should be reported.
The degree of fatigue following rapid, repetitive movements to report.
All modalities of sensation, including cortical, should be tested.
The method of testing should be recorded.
When a sensory deficit or pain described in a specific distribution, care must be taken to ensure that the findings are consistent with neuroanatomical facts. Suspected physiological observations should be noted.
Coordination should be tested.
The ability to perform fine motor dexterity and must be described.
In coordination or tremor at rest or during specific tests should be described in detail and quantified.
NOTE: The examples are given to describe the functional loss that occurs due to these events.
Highlights
Deep tendon reflexes should be described as the intensity and symmetry.
surface reflection must be described in the present and said in his absence.
Any pathological reflexes should be described in detail.
Any disturbance of speech or language should be described in detail a discussion of how much the ability of the applicant kept and how the doctor determines this. The report should discuss:
Aphasia;
Dysarthria;
Stuttering (fluency);
Involuntary vocalizations;
If speech is intelligible.
Mental Test state – should communicate and be extensive, when mental capacity is concerned. The physician should provide:
Examples of responses tests orientation, memory, calculation, perception, general knowledge and background of knowledge and
A detailed description of state mood and behavior during the examination, and any significant abnormality. Go to Listing of Impairments – Adults: 11,00 neurological for more information.
Mental Disorders
The report of psychiatric or psychological examination must show not only the claimant's signs, symptoms, findings laboratory (psychological test results), and diagnosis, but also describe the effect of emotional or mental disorder in the applicant's ability to function at the level of use and custom settings – personal, social and occupational.
General comments – Include in the report of the EC observations of a general nature:
How the applicant arrived at the exam:
Alone or accompanied;
The distance and mode of transport and
If by car, driving.
Appearance:
Dress,
Grooming
The attitude and level of cooperation.
Posture and gait.
General motor behavior, including involuntary movements.
Informant
The psychiatrist or psychologist must identify the person provides the story (usually the plaintiff) and should provide an estimate of the reliability of history.
Chief Complaint
Usually consist in the complainant's allegations in relation to any mental and / or physical problems.
History of Present Illness
This should include a detailed chronology of the onset and progression of the claimant's current mental / emotional state, with particular reference to:
Date and circumstances of the occurrence of the disease;
Date the claimant reported that the state started to interfere with work, and interference;
Date the claimant reported the inability to work due to the condition and circumstances;
Attempts to return to work and results;
Outpatient screening and treatment for mental / emotional problems, including:
The names of treatment sources;
Dates of treatment;
Types of Treatment (names and dosages of medications, if prescribed), and
The response to treatment.
Hospitalizations for mental disorders, including:
The names of the hospitals;
Dates and
Treatment and response.
Information about the complainant:
Activities of daily living;
Social functioning;
Ability to complete tasks on time and properly, and
Episodes of decompensation and their resulting effects.
Past History should give a line of the claimant's personal life, including:
Relevant educational, medical, social data, legal, military, civil and labor and associated problems in adjustment;
From the details (dates, places, etc) any history of outpatient treatment and hospitalizations for mental / emotional problems, and
History, where appropriate, substance abuse, and / or treatment at detoxification centers rehabilitation.
Mental State
The particular case facts, identify specific areas of the state of mind that is necessary stress test, but in general the report should include a detailed description of the claimant:
Appearance, behavior and language (If not already described);
Thought process (eg, loosening of associations);
thought content (eg delusions);
perceptual disturbances (eg hallucinations);
Mood and affect (eg depression, mania);
Sensory and cognition (eg, orientation, memory, memory, concentration, collection of information and intelligence);
Judgement and knowledge, and
ie, capacity (the individual is able to handle responsibly benefits provided?)
Diagnosis
American Psychiatric Association standard nomenclature as provided in the current "Diagnostic and Statistical Manual of Mental Disorders."
Prognosis
Prognosis and treatment recommendations, if indicated, also, any recommendations for medical evaluation (by example, neurological, general physical), if indicated.
Additional Needs for mental disorder
Schizophrenic delusional (paranoid), schizoaffective and other psychotic disorders – The report should reflect:
Periods of residence in structured settings as halfway 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 disease, if known, the prognosis, and
The existence of an acute or chronic;
Either stable or progressive, and
The changes at various points in time.
The results of psychological or neuropsychological tests that could be used to document further an organic process and its severity.
Information regarding the results of the neurological assessments.
Information
on neurological experiments (eg, EEG, CT) that may have led out and the results, if available.
In cases of mental retardation, the report should reflect:
The current documentation CI by a standardized and well established. Acceptable instruments will have a representative sample policy, with an average deviation of about 100 and the level of about 15 in the general population, and cover a wide range of cognitive functions and perceptual-motor (eg, Wechsler scales);
Verbal IQ, performance coefficient intellectual and scores of full-scale IQ, along with individual subtest scores;
The interpretation of the results and evaluation of the validity of the scores, indicating the factors that may have influenced the results such as the attitude of the applicant and the degree of cooperation, the presence of visual, auditory or other physical problems, and recent exposure prior to testing the same or similar, and
Consistency of test results obtained in education claimant's professional background, and social adjustment, especially in the sphere of personal autonomy.
About the Author
Greeman and Toomey is a law firm dedicated exclusively to assisting those seeking Social Security Disability Benefits. Visit online for a free and confidential consultation at http://www.minnesotaSocialSecurity.net
Additional Information
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