source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWBS1.m@ 804

DVBCWBS1 ;ALB/CMM BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  If flare-ups exist, describe precipitating factors, 
 ;;        aggravating factors, alleviating factors, alleviating 
 ;;        medications, frequency, severity, duration, and whether the 
 ;;        flare-ups include pain, weakness, fatigue, or functional loss.
 ;;
 ;;
 ;;    2.  Current treatment, response, and side effects.
 ;;
 ;;
 ;;    3.  State whether condition has stabilized.
 ;;
 ;;
 ;;    4.  Seizures - type, frequency.
 ;;
 ;;
 ;;    5.  Headache, dizziness, etc.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  If a tumor is or was present, note location, type, and 
 ;;        whether or not it is malignant.  If a malignancy is present 
 ;;        but is now cured or in remission, report the date of last 
 ;;        surgery, radiation therapy, chemotherapy, or other treatment.
 ;;
 ;;
 ;;    2.  Describe in detail the motor and sensory impairment of all 
 ;;        affected nerves.
 ;;
 ;;
 ;;    3.  Describe in detail any functional impairment of the peripheral
 ;;        and autonomic systems.
 ;;
 ;;TOF
 ;;    4.  A DETAILED ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
 ;;        a.  Using a goniometer, measure the PASSIVE and ACTIVE range 
 ;;            of motion, including movement against gravity and against
 ;;            strong resistance.
 ;;
 ;;
 ;;        b.  If the joint is painful on motion, state at what point in
 ;;            the range of motion pain begins and ends.
 ;;
 ;;
 ;;        c.  State to what extent, if any, the range of motion or 
 ;;            function is ADDITIONALLY LIMITED by pain, fatigue, weakness,
 ;;            or lack of endurance.  If more than one of these is 
 ;;            present, state, if possible, which has the major 
 ;;            functional impact.
 ;;
 ;;
 ;;    5.  Describe any psychiatric manifestations in detail - see 
 ;;        worksheets for mental disorders.
 ;;
 ;;
 ;;    6.  Eye examination.
 ;;
 ;;
 ;;    7.  State if the veteran has bladder or bowel functional impairment.  
 ;;        If present, state whether partial or total, intermittent or 
 ;;        constant and what measures are taken as a result of the impairment.
 ;;
 ;;
 ;;    8.  State if the veteran is capable of managing his or her benefit
 ;;        payments in his or her own best interest 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 the veteran is, by reason of 
 ;;        that disability, incapable of directing someone else in 
 ;;        handling the individual's financial affairs.)
 ;;
 ;;
 ;;    9.  If smell or taste is affected, also complete the appropriate 
 ;;        worksheet.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Skull X-rays to measure bony defect, if there was surgery; 
 ;;        spine X-rays if there was spinal cord surgery.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END