source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPF2.m@ 628

DVBCWPF2 ;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 ;
 ;;
 ;;F.  Assessment of PTSD
 ;;
 ;;    - identify the primary stressor or stressors
 ;;    - state whether or not the veteran meets the DSM-IV stressor criterion
 ;;    - identify behavioral, cognitive, social, affective, or somatic change(s)
 ;;      veteran attributes to stress exposure
 ;;    - describe specific PTSD symptoms present (symptoms of trauma
 ;;      re-experiencing, avoidance/numbing, heightened physiological arousal,
 ;;      and associated features [e.g., disillusionment and demoralization])
 ;;    - specify onset, duration, typical frequency, and severity of symptoms
 ;;    - state whether or not the current symptoms are linked to the identified
 ;;      stressor or stressors
 ;;
 ;;G.  Psychometric Testing Results
 ;;
 ;;    - provide psychological testing if deemed necessary.
 ;;    - provide specific evaluation information required by the rating board or
 ;;      on a BVA Remand.
 ;;    - comment on validity of psychological test results
 ;;    - provide scores for PTSD psychometric assessments administered
 ;;TOF
 ;;    - 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)
 ;;    - state degree of severity of PTSD symptoms based on psychometric data
 ;;      (mild, moderate, or severe)
 ;;    - describe findings from psychological tests measuring other than
 ;;      PTSD (MMPI, etc.)
 ;;
 ;;H.  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, discuss the relationship with
 ;;        PTSD.
 ;;    3.  The 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.
 ;;
 ;;I.  Diagnostic Status
 ;;
 ;;    -   Axis I disorders
 ;;    -   Axis II disorders
 ;;    -   Axis III disorders
 ;;    -   Axis IV (psychosocial and environmental problems)
 ;;    -   Axis V (GAF score - current)
 ;;
 ;;J.  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
 ;;TOF
 ;;    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.)
 ;;
 ;;    DSM-IV is only for application form 11/7/96 on.  Therefore, when
 ;;    applicable note whether the diagnosis for PTSD was supportable under
 ;;    DSM-III-R prior to that date.
 ;;
 ;;K.  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
 ;;       his or her 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.
 ;;
 ;;L.  Other Opinion:
 ;;
 ;;    Furnish any other specific opinion requested by the rating
 ;;    board or BVA remand (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 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.
 ;;
 ;;M.  Integrated Summary and Conclusions
 ;;
 ;;    - Describe changes in psychosocial functional status and quality of life
 ;;      following trauma exposure (performance in employment or schooling,
 ;;      routine responsibilities of self care, family role functioning, physical
 ;;      health, social/interpersonal relationships, recreation/leisure pursuits)
 ;;TOF
 ;;    - 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.
 ;;    - 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).
 ;;
 ;;    - If possible, describe pre-trauma risk factors or characteristics that
 ;;      may have rendered the veteran vulnerable to developing PTSD subsequent
 ;;      to trauma exposure.
 ;;    - If possible, state prognosis for improvement of psychiatric condition
 ;;      and impairments in functional status.
 ;;    - Comment on whether the veteran is capable of managing his/her
 ;;      benefit payments in his/her own best interest.