source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWME7.m@ 628

DVBCWME7 ;BPOIFO/RLC - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 12/26/06 2:23pm
 ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
 ;Per VHA Directive 10-92-142, this routine should not be modified
 ;
TXT ;
 ;;
 ;;The following health care providers can perform initial examinations for
 ;;Mental Disorders:
 ;;a board-certified or board "eligible" psychiatrist;
 ;;a licensed doctorate-level psychologist;
 ;;a doctorate-level mental health provider under the close supervision of a
 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
 ;;psychologist;
 ;;a psychiatry resident under close supervision of a board-certified or
 ;;board eligible psychiatrist or licensed doctorate-level psychologist; or
 ;;a clinical or counseling psychologist completing a one-year internship
 ;;or residency (for purposes of a doctorate-level degree) under close
 ;;supervision of a board-certified or eligible psychiatrist or licensed
 ;;doctorate-level psychologist.
 ;;
 ;;The following health care providers can perform review examinations for
 ;;Mental Disorders:
 ;;a board-certified or board "eligible" psychiatrist;
 ;;a licensed doctorate-level psychologist;
 ;;a doctorate-level mental health provider under close supervision of a
 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
 ;;psychologist;
 ;;a psychiatry resident under close supervision of a board-certified or board
 ;;eligible psychiatrist or licensed doctorate-level psychologist;
 ;;a clinical or counseling psychologist completing a one-year internship or
 ;;residency (for purposes of a doctorate-level degree) under close
 ;;supervision of a board-certified or board eligible psychiatrist or licensed
 ;;doctorate-level psychologist;
 ;;a licensed clinical social worker (LCSW); a nurse practitioner, a clinical
 ;;nurse specialist or physician assistant, if they are clinically privileged
 ;;to perform activities required for C&P mental disorder examinations, under
 ;;the close supervision of a board-certified or board eligible psychiatrist
 ;;or licensed doctorate-level psychologist.
 ;;
 ;;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,
 ;;           occupational and social history pre-military, military and since
 ;;           discharge from military service is required.
 ;;        c. Substance use and its consequences.
 ;;
 ;;    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. Social functioning and adjustment.
 ;;        d. Extent of time lost from work over the past 12 month period.
 ;;           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.
 ;;        e. Treatments including statement on effectiveness and side effects
 ;;           experienced.
 ;; 
 ;;    3. Subjective Complaints:
 ;;
 ;;        a. Describe fully.
 ;;
 ;;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 minimal 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 that interferes with routine
 ;;              activities.
 ;;           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. CAPACITY TO MANAGE FINANCIAL AFFAIRS Mental competency, for
 ;;           VA benefits purposes, refers only to the ability of the veteran
 ;;           to manage VA benefit payments in his or her own best interest,
 ;;           and not to any other subject. Mental incompetence, for VA benefits
 ;;           purposes, means that the veteran, because of injury or disease,
 ;;           is not capable of managing benefit payments in his or her best
 ;;           interest. In order to assist raters in making a legal determination
 ;;           as to competency, please address the following:
 ;;             - What is the impact of injury or disease on the veteran's ability
 ;;               to manage his or her financial affairs, including consideration
 ;;               of such things as knowing the amount of his or her VA benefit
 ;;               payment, knowing the amounts and types of bills owed monthly,
 ;;               and handling the payment prudently? Does the veteran handle
 ;;               the money and pay the bills?
 ;;
 ;;             - Based on your examination, do you believe that the veteran is
 ;;               capable of managing his or her financial affairs?
 ;;             - Please provide examples to support your conclusion.
 ;;
 ;;               If you believe a Social Work Service assessment is needed before
 ;;               you can give your opinion on the veteran's ability to manage his
 ;;               or her financial affairs, please explain why.
 ;;
 ;;           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 undertaken.
 ;;              If the requested opinion is medically not ascertainable on exam
 ;;              or testing, please indicate why. If the requested opinion cannot
 ;;              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.
 ;;