source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPG1.m@ 628

DVBCWPG1 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ;05/18/2006 12:00pm
 ;;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 review examinations for PTSD:
 ;;
 ;;     - 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 the 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 a physician assistant, if they are
 ;;       clinically privileged to perform activities required for C&P mental
 ;;       disorder examinations, under close supervision of a board certified
 ;;       or board eligible psychiatrist or doctorate-level psychologist.
 ;;
 ;;A.  Review of Medical Records
 ;;
 ;;B.  Medical History since last exam:
 ;;
 ;;     Comment on:
 ;;
 ;;     1.  Hospitalizations and outpatient care from the time between last
 ;;         rating examination to 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.  Significant medical disorders (resulting pain or disability; current
 ;;         medications).
 ;;     3.  Frequency, severity and duration of psychiatric symptoms.
 ;;     4.  Length of remissions from psychiatric symptoms, to include capacity
 ;;         for adjustment during periods of remissions.
 ;;     5.  Treatments including statement on effectiveness and side effects
 ;;         experienced.
 ;;     6.  Subjective Complaints: Describe fully.
 ;;
 ;;C.  Psychosocial Adjustment since the last exam
 ;;
 ;;    - legal history (DWIs, arrests, time spent in jail)
 ;;    - educational accomplishment
 ;;TOF
 ;;    - 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.
 ;;    - marital and family relationships (including quality of relationships
 ;;      with spouse and children)
 ;;    - degree and quality of social relationships
 ;;    - activities and leisure pursuits
 ;;    - substance use and consequences of substance us
 ;;      medications)
 ;;    - history of violence/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
 ;;      relationship, recreation/leisure pursuits)
 ;;
 ;;D.  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