source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWMD1.m@ 628

DVBCWMD1 ;ALB/CMM MENTAL DISORDERS WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical history (subjective complaints):
 ;;
 ;;    Comment on:
 ;;    1.  PAST MEDICAL HISTORY:
 ;;
 ;;        a.  Previous hospitalizations and outpatient care.
 ;;
 ;;
 ;;        b.  Medical and occupational history from the time between 
 ;;            last rating examination and the present, UNLESS the 
 ;;            purpose of this examination is to ESTABLISH service 
 ;;            connection, then the complete medical history since 
 ;;            discharge from military service is required.
 ;;
 ;;
 ;;    2.  PRESENT MEDICAL, OCCUPATIONAL, AND SOCIAL HISTORY - over the 
 ;;        past one year.
 ;;
 ;;        a.  Frequency, severity, and duration of psychiatric symptoms.
 ;;
 ;;        b.  Length of remissions, to include capacity for adjustment 
 ;;            during periods of remissions.
 ;; 
 ;;        c.  Extent of time lost from work over the past 12 month 
 ;;            period and social impairment.  If employed, identify 
 ;;            current occupation and length of time at this job.  If 
 ;;            unemployed, note in complaints whether veteran contends it
 ;;            is due to the effects of a mental disorder.  Further 
 ;;            indicate following DIAGNOSIS what factors, and objective 
 ;;            findings support or rebut that contention.
 ;;
 ;;        d.  Treatments including statement on effectiveness and side 
 ;;            effects experienced.
 ;; 
 ;;    3.  SUBJECTIVE COMPLAINTS:
 ;;
 ;;        a.  Describe fully.
 ;;
 ;;TOF
 ;;C.  Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe:
 ;;    1.  Mental status exam to confirm or establish diagnosis in 
 ;;        accordance with DSM-IV.
 ;;
 ;;    2.  Additionally, to allow evaluation by the rating specialist, 
 ;;        describe and fully explain the existence, frequency, and 
 ;;        extent of the following signs and symptoms, or any others 
 ;;        present, and relate how they interfere with employment and 
 ;;        social functioning:
 ;; 
 ;;        a.  Impairment of thought process or communication.
 ;; 
 ;;
 ;;        b.  Delusions, hallucinations and their persistence.
 ;; 
 ;; 
 ;;        c.  Inappropriate behavior cited with examples.
 ;; 
 ;;
 ;;        d.  Suicidal or homicidal thoughts, ideations or plans or intent.
 ;;
 ;;
 ;;        e.  Ability to maintain personal hygiene and other basic 
 ;;            activities of daily living.
 ;; 
 ;;        f.  Orientation to person, place, and time.
 ;;
 ;;
 ;;        g.  Memory loss or impairment (both short and/or long term).
 ;; 
 ;; 
 ;;        h.  Obsessive or ritualistic behavior which interferes with 
 ;;            routine activities (describe with examples).
 ;; 
 ;; 
 ;;        i.  Rate and flow of speech and note irrelevant, illogical, or
 ;;            obscure speech patterns and whether constant or intermittent.
 ;; 
 ;; 
 ;;        j.  Panic attacks noting the severity, duration, frequency and
 ;;            effect on independent functioning and whether clinically
 ;;            observed or good evidence of prior clinical or equivalent
 ;;            observation.
 ;; 
 ;;        k.  Depression, depressed mood, or anxiety.
 ;;
 ;;        l.  Impaired impulse control and its effect on motivation or mood.
 ;;
 ;;
 ;;        m.  Sleep impairment and describe extent it interferes with 
 ;;            daytime activities.
 ;;
 ;;
 ;;        n.  Other symptoms and the extent to which they interfere with
 ;;            activities.
 ;;
 ;;
 ;;D.  Diagnostic Tests:
 ;;
 ;;    1.  Provide psychological testing if deemed necessary.
 ;;    2.  If testing is requested, the results must be reported and 
 ;;        considered in arriving at the diagnosis.
 ;;    3.  Provide any specific evaluation information required by the 
 ;;        rating board or on BVA Remand (in claims folder).
 ;;
 ;;        a.  COMPETENCY:  State whether the veteran is capable of 
 ;;            managing his/her benefit payments in the individual's own
 ;;            best interests (a physical disability which prevents the 
 ;;            veteran from attending to financial matters in person is 
 ;;            not a proper basis for a finding of incompetency unless 
 ;;            the veteran is, by reason of that disability, incapable of
 ;;            directing someone else in handling the individual's 
 ;;            financial affairs).
 ;;
 ;;        b.  OTHER OPINION:  Furnish any other specific opinion requested 
 ;;            by the rating board or BVA Remand furnishing the complete
 ;;            rationale and citation of medical texts or treatise 
 ;;            supporting opinion, if medical literature review was under-
 ;;            taken. If the requested opinion is medically not ascertainable 
 ;;            on exam or testing, please indicate why.  If the requested
 ;;            opinion can not be expressed without resorting to 
 ;;            speculation or making improbable assumptions say so, and 
 ;;            explain why.  If the opinion asks "...is it at least as 
 ;;            likely as not..?", fully explain the clinical findings and
 ;;            rationale for the opinion.
 ;;
 ;;    4.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;TOF
 ;;E.  Diagnosis: 
 ;;
 ;;    Provide:
 ;;    1.  The Diagnosis must conform to DSM-IV and be supported by the 
 ;;        findings on the examination report.
 ;;    2.  If the diagnosis is changed, explain fully whether the new 
 ;;        diagnosis represents a progression of the prior diagnosis or 
 ;;        development of a new and separate condition.
 ;;    3.  If there are multiple psychiatric conditions, delineate to the
 ;;        extent possible the symptoms associated with each and a 
 ;;        discussion of relationship.
 ;;    4.  Evaluation is based on the effects of the signs and symptoms 
 ;;        on occupational and social functioning.
 ;;
 ;;NOTE:  VA is prohibited by statute from paying compensation for a 
 ;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, 
 ;;whether based on direct service connection, secondary service connection, 
 ;;or aggravation by a service-connected condition.  Therefore, when 
 ;;alcohol or drug abuse accompanies or is associated with another mental
 ;;disorder, separate, to the extent possible, the effects of the alcohol
 ;;or drug abuse from the effects of the other mental disorder(s).  If it
 ;;is not possible to separate the effects, explain why.
 ;;
 ;;
 ;;
 ;;F.  Global Assessment of Functioning (GAF):
 ;;
 ;;NOTE:  The complete multi-axial format as specified by DSM-IV may 
 ;;be required by BVA REMAND or specifically requested by the rating 
 ;;specialist.  If so, include the GAF score and note whether it 
 ;;refers to current functioning over the past year, etc.
 ;;
 ;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent 
 ;;possible, to provide a GAF score for the service connected conditions
 ;;alone as well as a separate overall GAF score based on all mental 
 ;;disorders present and explain and discuss the rationale.  (See the 
 ;;above note pertaining to alcohol or drug abuse, effects of which cannot 
 ;;be used to assess the effects of a service-connected condition.)  If 
 ;;unable to separate symptomatology, explain why.
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END