Conducting the Examination: History, Physical, and Required Testing
History and examination
The MCSA-5875 structures the encounter. The health history covers medications, allergies, prior surgeries and hospitalizations, and a system-by-system review. Ask specifically about chest pain, dyspnea, palpitations, syncope, seizures, daytime sleepiness, insulin or other hypoglycemia-prone drugs, alcohol and drug use, and sedating medication. Record critical answers in the driver's own words, especially denials that later matter.
The physical examination includes height, weight, blood pressure, pulse, general appearance, eyes, ears/nose/throat, heart, lungs, abdomen, vascular system, skin, musculoskeletal system, neurologic system, and mental status. Required testing is limited: distance visual acuity in each eye and both eyes together, horizontal visual field, color vision; hearing by forced whisper at five feet (or an audiogram); and urinalysis for specific gravity, protein, glucose, and blood-the only mandated laboratory study.
Not part of the examination
Electrocardiogram, chest x-ray, blood chemistries, PSA, sleep study, audiometry when the whisper test is used, and the DOT drug test. Drug testing is a separate program under Part 382 and Part 40; the ME does not collect a specimen as part of the certification examination, and a negative drug test does not substitute for any medical finding.
Traps
- Confusing the examination urinalysis with a drug screen.
- Accepting a previous examiner's certificate instead of performing an examination.
- Acting on one elevated blood pressure reading without proper technique or a repeat measurement.
- Charting "WNL" without recording the numbers.
- Substituting the treating physician's notes for the ME's own findings.
Rule of thumb
If it was not documented, it was not done; if the finding is a number-blood pressure, acuity, decibels-write the number.