[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 274-275]

 

                      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 275]]



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.