source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWAH1.m@ 1154

DVBCWAH1 ;ALB/CMM A&A OR HOUSEBOUND WKS TEXT - 1 ; 7 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;NARRATAIVE:  Once the existence of at least a single disability rated
 ;;at 100% has been established, additional benefits may be payable if 
 ;;the veteran requires:
 ;;
 ;;      1.  The regular assistance of another person in attending to the
 ;;          ordinary hazards of daily living.
 ;;      2.  Assistance of another in protecting himself or herself from
 ;;          the ordinary hazards of his or her daily environment, and/or
 ;;      3.  If the veteran is restricted to his or her home or the immediate
 ;;          vicinity thereof, including the ward or immediate clinical
 ;;          area, if hospitalized.
 ;;
 ;;
 ;;A.  Review Of Medical Records:
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    1.  Indicate whether or not the veteran requires an attendant in
 ;;        reporting for this exam, and if so, identify the nurse or attendant
 ;;        and the mode of travel employed.
 ;;
 ;;
 ;;    2.  Indicate whether or not the veteran is hospitalized, and if so, 
 ;;        state where and the date of admission.
 ;;
 ;;
 ;;    3.  Indicate whether or not the veteran is permanently bedridden.
 ;;
 ;;
 ;;    4.  Indicate whether of not the veteran's best corrected vision is
 ;;        5/200 or worse in both eyes.
 ;;
 ;;
 ;;    5.  State whether the veteran is capable of managing benefit patments
 ;;        in his or her own best interests without restriction.  (A physical 
 ;;        disability which prevents the veteran from attending to financial 
 ;;        matters in person is not a proper basis for a finding of incompetency 
 ;;        unless he or she is, by reason of that disability, incapable or 
 ;;        directing someone else in handling financial affairs.)
 ;;
 ;;
 ;;    6.  Capacity to protect oneself from the hazards/dangers of daily
 ;;        environment:
 ;;
 ;;        a.  Describe briefly any pathological processes involving other
 ;;            body parts and systems, including the effects of advancing
 ;;            age, such as dizziness, bowel/bladder incontinence, loss of 
 ;;            memory, poor balance affecting ability to ambulate, performing
 ;;            self-care, or travel beyond the premises of the home (or the 
 ;;            ward or clinical area if hospitalized).
 ;;
 ;;
 ;;        b.  Describe where the veteran goes and what he or she does 
 ;;            during a typical day.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings): 
 ;;
 ;;    Comment on:
 ;;    1.  General Appearance.
 ;;
 ;;
 ;;    2.  Height and weight (including maximum and minimum weight for past year.
 ;;
 ;;
 ;;    3.  Build and posture.
 ;;
 ;;
 ;;    4.  State of nutrition.
 ;;
 ;;
 ;;    5.  Gait.
 ;;
 ;;
 ;;    6.  Temperature, pulse, respiration.
 ;;
 ;;
 ;;    7.  Blood Pressure.
 ;;
 ;;
 ;;    8.  Upper extremities (reporting each upper extremity separately):
 ;;
 ;;        a.  Describe functional restrictions with reference to 
 ;;            strength and coordination and ability for self-feeding, 
 ;;            fastening clothing, bathing, shaving, and toileting.  
 ;;
 ;;
 ;;        b.  If amputated, indicate level of amputation (or length of 
 ;;            stump and  whether or not use of a prosthesis is feasible).
 ;;
 ;;    9.  Lower extremities (reporting each lower extremity separately):
 ;;
 ;;        a.  Describe functional restrictions with reference to extent
 ;;            of limitation of motion, muscle atrophy, contractures, 
 ;;            weakness, lack of coordination, or other interference.
 ;;
 ;;
 ;;        b.  Indicate any deficits of weight bearing, balance, and propulsion.
 ;;
 ;;
 ;;        c.  If amputated, indicate level of amputation (or length of 
 ;;            stump and whether use of a prosthesis is feasible).
 ;;
 ;;
 ;;   10.  Spine, trunk and neck:
 ;;        Describe any limitation of motion or deformity of lumbar, 
 ;;        thoracic, and cervical spine.
 ;;
 ;;
 ;;   11.  Note if deformity of thoracic spine interferes with breathing.
 ;;
 ;;
 ;;   12.  Ambulation:
 ;;
 ;;        a.  Indicate whether the veteran is able to walk without the 
 ;;            assistance of another person and give the maximum distance.
 ;;
 ;;
 ;;        b.  Indicate any mechanical aid used or recommended by the examiner.
 ;;
 ;;
 ;;        c.  Indicate the frequency, and under what circumstances, the
 ;;            veteran is able to leave the home or immediate premises.
 ;;
 ;;   13.  Except as to amputations and other anatomical losses, indicate
 ;;        if any restrictions noted in the examination are permanent.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  No specific diagnostic testing required unless required to evaluate
 ;;        the veteran as required above.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END