source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPF1.m@ 628

DVBCWPF1 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ;05/18/2006 11:00am
 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
 ;Per VHA Directive 10-92-142, this routine should not be modified
 ;
TXT ;
 ;;
 ;;The following health care providers can perform initial examinations for PTSD:
 ;;
 ;;   - 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 board eligible psychiatrist or
 ;;     licensed doctorate-level psychologist.
 ;;
 ;;A.  Identifying Information
 ;;
 ;;    - age
 ;;    - ethnic background
 ;;    - era of military service
 ;;    - reason for referral (original exam to establish PTSD diagnosis and
 ;;      related psychosocial impairment; re-evaluation of status of existing
 ;;      service-connected PTSD condition)
 ;;
 ;;B.  Sources of Information
 ;;
 ;;    - records reviewed (C-file, DD-214, medical records, other documentation)
 ;;    - review of social-industrial survey completed by social worker
 ;;    - statements from collaterals
 ;;    - administration of psychometric tests and questionnaires (identify here)
 ;; 
 ;;C.  Review of Medical Records:
 ;;
 ;;    1.  Past Medical History:
 ;;
 ;;        a.  Previous hospitalizations and outpatient care.
 ;;        b.  Complete medical history is required, including history since
 ;;            discharge from military service.
 ;;        c.  Review of Claims Folder is required on initial exams to establish
 ;;            or rule out the diagnosis.
 ;;
 ;;    2.  Present Medical History - over the past one year.
 ;;
 ;;        a.  Frequency, severity and duration of medical and psychiatric
 ;;            symptoms.
 ;;TOF
 ;;        b.  Length of remissions, to include capacity for adjustment during
 ;;            periods of remissions.
 ;;
 ;;D.  Examination (Objective Findings):
 ;;    Address each of the following and fully describe:
 ;;
 ;;    History (Subjective Complaints):
 ;;    Comment on:
 ;;
 ;;         Premilitary History (refer to social-industrial survey if completed)
 ;;
 ;;       - describe family structure and environment where raised (identify
 ;;         constellation of family members and quality of relationships)
 ;;       - quality of peer relationships and social adjustment (e.g., activities,
 ;;         achievements, athletic and/or extracurricular involvements, sexual
 ;;         involvements, etc.)
 ;;       - education obtained and performance in school
 ;;       - employment
 ;;       - legal infractions
 ;;       - delinquency or behavior conduct disturbances
 ;;       - substance use and consequences of substance use
 ;;       - significant medical problems and treatments obtained
 ;;       - family psychiatric history
 ;;       - exposure to traumatic stressors (see CAPS trauma assessment checklist)
 ;;       - summary assessment of psychosocial adjustment and progression through
 ;;         developmental milestones (performance in employment or schooling,
 ;;         routine responsibilities of self-care, family role functioning,
 ;;         physical health, social/interpersonal relationship, recreation/leisure
 ;;         pursuits).
 ;;
 ;;         Military History
 ;;
 ;;       - branch of service (enlisted or drafted)
 ;;       - dates of service
 ;;       - dates and location of war zone duty and number of months stationed
 ;;         in war zone
 ;;       - Military Occupational Specialty (describe nature and duration of job(s)
 ;;         in war zone)
 ;;       - highest rank obtained during service (rank at discharge if different)
 ;;       - type of discharge from military
 ;;       - substance use and consequences of substance use
 ;;       - combat wounds sustained (describe)
 ;;       - clearly describe the specific stressor event(s) veteran considers
 ;;         particularly traumatic, particularly, if the stressor is a type
 ;;         of personal assault, including sexual assault, provide information,
 ;;         with examples, if possible
 ;;       - indicate overall level of traumatic stress exposure
 ;;         (high, moderate, low) based on frequency and severity of incident
 ;;         exposure
 ;;       - citations or medals received
 ;;       - disciplinary infractions or other adjustment problems during military
 ;;TOF
 ;;   NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
 ;;   medical evidence establishing a diagnosis of the condition that conforms
 ;;   to the diagnostic criteria of DSM-IV, credible supporting evidence that
 ;;   the claimed in-service stressor actually occurred, and a link, established
 ;;   by medical evidence, between current symptomatology and the claimed
 ;;   in-service stressor.  It is the responsibility of the examiner to describe
 ;;   the traumatic stressor leading to PTSD, if he or she makes the diagnosis
 ;;   of PTSD.
 ;;
 ;;   A diagnosis of PTSD cannot be adequately documented or ruled out without
 ;;   obtaining a detailed military history and reviewing the claims folder. 
 ;;   This means that initial review of the folder prior to examination, the
 ;;   history and examination itself, and the dictation for an examination
 ;;   initially establishing PTSD will often require more time than for 
 ;;   examinations of other disorders.  Ninety minutes to two hours on an
 ;;   initial exam is normal.
 ;;
 ;;     Post-Military Trauma History (refer to social-industrial survey if
 ;;     completed)
 ;;
 ;;   - describe post-military traumatic events (see CAPS trauma assessment
 ;;     checklist)
 ;;   - describe psychosocial consequences of post-military trauma exposure(s)
 ;;     (treatment received, disruption to work, adverse health consequences)
 ;;
 ;;     Post-Military Psychosocial Adjustment (refer to social-industrial survey
 ;;     if completed)
 ;;
 ;;   - legal history (DWIs, arrests, time spent in jail)
 ;;   - educational accomplishment
 ;;   - employment history (describe periods of unemployment and reasons)
 ;;   - marital and family relationships (including quality of relationships with
 ;;     children)
 ;;   - degree and quality of social relationships
 ;;   - activities and leisure pursuits
 ;;   - substance use and consequences of substance use
 ;;   - significant medical disorders (resulting pain or disability; current
 ;;     medications)
 ;;   - treatment history for significant medical conditions, including 
 ;;     hospitalizations
 ;;   - history of inpatient and/or outpatient psychiatric care (dates and
 ;;     conditions treated)
 ;;   - history of assaultiveness
 ;;   - history of suicide attempts
 ;;   - summary statement of current psychosocial functional status (performance
 ;;     in employment or schooling, routine responsibilities of self care,
 ;;     family role functioning, physical health, social/interpersonal
 ;;     relationships, recreation/leisure pursuits).
 ;;TOF
 ;;E.  Mental Status Examination
 ;;
 ;;    Conduct a mental status examination aimed at screening for DSM-IV
 ;;    mental disorders. 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:
 ;;
 ;;    - Impairment of thought process or communication
 ;;    - Delusions, hallucinations and their persistence
 ;;    - Eye Contact, interaction in session, and inappropriate behavior cited
 ;;      with examples
 ;;    - Suicidal or homicidal thoughts, ideations or plans or intent
 ;;    - Ability to maintain minimal personal hygiene and other basic activities
 ;;      of daily living
 ;;    - Orientation to person, place, and time
 ;;    - Memory loss, or impairment (both short and long-term)
 ;;    - Obsessive or ritualistic behavior that interferes with routine activities
 ;;    - Rate and flow of speech and note any irrelevant, illogical, or obscure
 ;;      speech patterns and whether constant or intermittent
 ;;    - 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 is shown
 ;;    - Depression, depressed mood or anxiety
 ;;    - Impaired impulse control and its effect on motivation or mood
 ;;    - Sleep impairment and describe extent it interferes with daytime
 ;;      activities
 ;;    - Other disorders or symptoms and the extent they interfere with activities