source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPE7.m@ 628

DVBCWPE7 ;BPOIFO/ESW - REVIEW PTSD WORKSHEET TEXT ; 10/1/02 5:48pm
 ;;2.7;AMIE;**46**;Apr 10, 1995
 ;Per VHA Directive 10-92-142, this routine should not be modified
 ;
TXT ;
 ;;E. Assessment of PTSD
 ;;
 ;;    1. state whether or not the veteran meets the DSM-IV stressor criterion
 ;;    2. identify behavioral, cognitive, social, affective, or somatic symptoms
 ;;       veteran attributes to PTSD
 ;;    3. describe specific PTSD symptoms present (symptoms of trauma
 ;;       re-experiencing, avoidance/numbing, heightened physiological arousal,
 ;;       and associated features [e.g., disillusionment and demoralization])
 ;;    4. specify typical frequency, and severity of symptoms
 ;;TOF
 ;;F. Psychometric Testing Results
 ;;
 ;;   1. provide psychological testing if deemed necessary
 ;;   2. provide specific evaluation information required by the rating board or
 ;;      on a BVA Remand
 ;;   3. comment on validity of psychological test results
 ;;   4. provide scores for PTSD psychometric assessments administered
 ;;   5. state whether PTSD psychometric measures are consistent or inconsistent
 ;;      with a diagnosis of PTSD, based on normative data and established
 ;;      "cutting scores" (cutting scores that are consistent with or supportive
 ;;      of a PTSD diagnosis are as follows: PCL - not less than 50;
 ;;      Mississippi Scale - not less than 107; MMPI PTSD subscale a score
 ;;      greater than 28; MMPI code type: 2-8 or 2-7-8)
 ;;   6. state degree of severity of PTSD symptoms based on psychometric data
 ;;      (mild, moderate, or severe)
 ;;   7. describe findings from psychological tests measuring other than
 ;;      PTSD (MMPI, etc.)
 ;;
 ;;G. Diagnosis:
 ;;
 ;;    1. The Diagnosis must conform to DSM-IV and be supported by the findings
 ;;       on the examination report.
 ;;    2. If there are multiple mental disorders, delineate to the extent possible
 ;;       the symptoms associated with each and a discussion of relationship.
 ;;    3. Evaluation is based on the effects of the signs and symptoms on
 ;;       occupational and social functioning.
 ;;
 ;;NOTE:  VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
 ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
 ;;However, when a veteran's alcohol or drug abuse disability is secondary to
 ;;or is caused or aggravated by a primary service-connected disorder, the  
 ;;veteran may be entitled to compensation.  See Allen v. Principi, 237 F.3d
 ;;1368, 1381 (Fed. Cir. 2001).  Therefore, it is important to determine the
 ;;relationship, if any, between a service-connected disorder and a disability
 ;;resulting from the veteran's alcohol or drug abuse.  Unless alcohol or drug
 ;;abuse is secondary to or is caused or aggravated by another mental disorder,
 ;;you should 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 in such cases, please explain why.
 ;;
 ;;H. Diagnostic Status
 ;;
 ;;      Axis I disorders
 ;;      Axis II disorders
 ;;      Axis III disorders
 ;;      Axis IV (psychosocial and environmental problems)
 ;;      Axis V (GAF score - current)
 ;;
 ;;TOF
 ;;I. 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.
 ;;    A BVA REMAND may also request, in addition to an overall GAF score,
 ;;    that a separate GAF score be provided for each mental disorder present when
 ;;    there are multiple Axis I or Axis II diagnoses and not all are service-
 ;;    connected. If separate GAF scores can be given, an explanation and
 ;;    discussion of the rationale is needed. If it is not possible, an explanation
 ;;    as to why not is needed. (See the above note pertaining to alcohol or drug
 ;;    abuse.)
 ;;
 ;;J. 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 incompetency,
 ;;       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 himself or herself?
 ;;
 ;;             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.
 ;;
 ;;K. Other Opinion:
 ;;
 ;;   Furnish any other specific opinion requested by the rating
 ;;   board or BVA remand (i.e., furnish 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 state 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.
 ;;TOF
 ;;L. Integrated Summary and Conclusions
 ;;
 ;;   1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
 ;;      since the last exam (performance in employment or schooling, routine
 ;;      responsibilities of self care, family role functioning, physical health,
 ;;      social/interpersonal relationships, recreation/leisure pursuits)
 ;;   2. Describe linkage between PTSD symptoms and aforementioned changes in
 ;;      impairment in functional status and quality of life. 
 ;;        Particularly in cases where a veteran is unemployed, specific details
 ;;        about the effects of PTSD and its symptoms on employment are especially 
 ;;        important.
 ;;
 ;;   3. If possible, describe extent to which disorders other than PTSD
 ;;      (e.g., substance use disorders) are independently responsible for
 ;;      impairment in psychosocial adjustment and quality of life. If this is not
 ;;      possible, explain why (e.g., substance use had onset after PTSD
 ;;      and clearly is a means of coping with PTSD symptoms).
 ;;   4. If possible, state prognosis for improvement of psychiatric condition
 ;;      and impairments in functional status.
 ;;   5. Comment on whether veteran should be rated as competent for VA purposes
 ;;      in terms of being capable of managing his/her benefit payments in his/her
 ;;      own best interest.
 ;;
 ;;
 ;;Signature:                              Date:
 ;;END