What the evaluation is for
Social Security’s Disability Determination Services (DDS) may purchase a consultative examination, or CE, when the available evidence is insufficient. The requested examination or testing depends on the missing information. The examiner supplies clinical findings and an opinion; the agency makes the disability determination. See SSA’s consultative examination guidance.
This guide concerns adult mental health CEs for Social Security disability claims. Start with the actual DDS request, including any requested testing and state-specific instructions.
What the examination covers
SSA’s adult mental-disorder report guidance calls for a documented history, identification of the records and informants used, a mental status examination, diagnosis, prognosis, and a supported opinion about functional limitations. It also addresses treatment response, medication effects, daily activities, work attempts, and the person’s ability to manage funds.
The functional discussion includes understanding and carrying out instructions, sustaining concentration and pace, interacting with others, and handling ordinary workplace pressures. A mental status examination describes the examiner’s observations; reported symptoms remain attributed to the person who described them. Additional requirements depend on the condition being evaluated. See SSA POMS DI 22510.112.
Organize the records around the questions
For preparation, create a short evidence index rather than an undifferentiated stack of notes:
Keep record dates and event dates separate. For example, a recent intake may describe a much earlier hospitalization; the intake date does not establish when the hospitalization occurred.
Before writing the report
Use the index to build a manageable follow-up list:
- Identify records mentioned in the packet that were not actually supplied.
- Flag differing accounts without deciding that the newest account is necessarily correct.
- Distinguish a person’s description of an activity from an examiner’s observation of it.
- Mark statements that need to be checked against the original page.
- Revisit the DDS request before finalizing the report so the requested question remains visible.
These are record-preparation suggestions, not a replacement for the agency’s report requirements.
Where PsyReview fits
PsyReview helps organize the supplied medical history into a source-linked review. Use it to prepare a chronology, locate supporting passages, and bring unresolved questions into the examination. Check generated content against the original records before incorporating it into your work.
The clinical examination, interpretation of testing, and professional opinion remain the examiner’s work. PsyReview does not determine Social Security eligibility or submit a CE report to DDS.
Sources and scope
- SSA: Consultative Examination Guidelines.
- SSA POMS: Adult CE Report Content Guidelines for Mental Disorders, revised July 16, 2025.
Sources checked November 4, 2026. This is an editorial preparation guide for clinicians, not an SSA form or an agency-endorsed workflow. Childhood disability evaluations have different requirements.