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What must be in the report for an SSD consultative examination?

Oklahomans who are applying for Social Security disability benefits due to an injury, illness or condition that renders them unable to work should understand the basics of filing a claim including how medical evidence is used. When Disability Determination Services is assessing a case for the Social Security Administration and the medical evidence presented by the claimant’s physician is deemed insufficient to come to a fair determination, a consultative examination might be needed. With a consultative examination, it is important to understand what must be in the report.

The physician who performs the consultative examination will need to be told of the claimant’s complaints. The physician’s findings must be based on the exam, the claimant’s history, laboratory tests as needed and other factors that were or were not found. If, for example, the applicant needed an X-ray or MRI, its results must be in the report. These must also be performed based on the Listing of Impairments and its guidelines.

Adults who are seeking benefits and have a consultative examination will need a statement as to what he or she can do with the impairment. The report must also say if there is an impairment or more than one impairment-based restriction in certain abilities necessary to perform the basic functions of a job including the ability to stand, sit, walk, push, pull and do basic physical duties.

Other aspects of work that will be analyzed in the report are if the person has the mental capabilities to perform work with the ability to understand, remember, follow instructions, concentrate, have proper pace, and accept supervision and shared duties. The senses will be gauged for functionality. Environmental conditions like the varying temperatures are part of the report.

The SSD case generally hinges on the medical evidence and having an accurate assessment is critical. Being asked to take part in a consultative examination does not mean the case is set to be denied. It simply means that there is not enough evidence for the DDS and the SSA to make an immediate decision based on the information it has. Still, it is wise to know what must be in the report by the independent physician and to be prepared for the case from the start. Being represented by a law firm that specializes in Social Security disability claims can be beneficial for full preparation in seeking an approval for benefits.

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