[Code of Federal Regulations]
[Title 20, Volume 1]
[Revised as of April 1, 2005]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR220.61]

[Page 256-257]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
                  CHAPTER II--RAILROAD RETIREMENT BOARD
 
PART 220_DETERMINING DISABILITY--Table of Contents
 
                   Subpart G_Consultative Examinations
 
Sec. 220.61  Informing the examining physician or psychologist of 
examination scheduling, report content and signature requirements.

    Consulting physicians or psychologists will be fully informed at the 
time the Board contacts them of the following obligations:
    (a) General. In scheduling full consultative examinations, 
sufficient time should be allowed to permit the examining physician to 
take a case history and perform the examination (including any needed 
tests).
    (b) Report content. The reported results of the claimant's medical 
history, examination, pertinent requested laboratory findings, 
discussions and conclusions must conform to accepted professional 
standards and practices in the medical field for a complete and 
competent examination. The facts in a particular case and the 
information and findings already reported in the medical and other 
evidence of record will dictate the extent of detail needed in the 
consultative examination report for that case. Thus, the detail and 
format for reporting the results of a purchased examination will vary 
depending upon the type of examination or testing requested. The 
reporting of information will differ from one type of examination to 
another when the requested examination relates to the performance of 
tests such as ventilatory function tests, treadmill exercise tests, or 
audiological tests. The medical report must be complete enough to help 
the Board determine the nature, severity, duration of the impairment, 
and residual functional capacity. Pertinent points in the claimant's 
medical history, such as a description of chest pain, will reflect the 
claimant's statements of his or her symptoms, not simply the physician's 
or psychologist's statements or conclusions. The examining physician's 
or psychologist's report of the consultative examination will include 
the objective medical facts.
    (c) Elements of a complete examination. A complete examination is 
one which involves all the elements of a standard examination in the 
applicable medical specialty. When a complete examination is involved, 
the report will include the following elements:
    (1) The claimant's major or chief complaint(s).
    (2) A detailed description, within the area of speciality of the 
examination, of the history of the claimant's major complaint(s).
    (3) A description, and disposition, of pertinent ``positive,'' as 
well as ``negative,'' detailed findings based on the history, 
examination and laboratory test(s) related to the major complaint(s) and 
any other abnormalities reported or found during examination or 
laboratory testing.
    (4) The results of laboratory and other tests (e.g., x-rays) 
performed according to the requirements stated in the Listing of 
Impairments (see appendix 1 of this part).
    (5) The diagnosis and prognosis for the claimant's impairment(s).
    (6) A statement as to what the claimant can still do despite his or 
her impairment(s) (except in disability claims for remarried widows and 
widowers, and surviving divorced spouses). This statement must describe 
the consultative physician's or psychologist's opinion concerning the 
claimant's ability, despite his or her impairment(s), to do basic work 
activities such as sitting, standing, lifting, carrying, handling 
objects, hearing, speaking, and traveling: and, in cases of mental 
impairment(s), the consultative physician's or psychologist's opinion as 
to the claimant's ability to reason or make occupational, personal, or 
social adjustments.
    (7) When less than a complete examination is required (for example, 
a specific test or study is needed), not every element is required.
    (d) Signature requirements. All consultative examination reports 
will be personally reviewed and signed by the physician or psychologist 
who actually performed the examination. This attests to the fact that 
the physician or psychologist doing the examination or

[[Page 257]]

testing is solely responsible for the report contents and for the 
conclusions, explanations or comments provided with respect to the 
history, examination and evaluation of laboratory test results.