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1DVBCWMD1 ;ALB/CMM MENTAL DISORDERS WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical history (subjective complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. PAST MEDICAL HISTORY:
14 ;;
15 ;; a. Previous hospitalizations and outpatient care.
16 ;;
17 ;;
18 ;; b. Medical and occupational history from the time between
19 ;; last rating examination and the present, UNLESS the
20 ;; purpose of this examination is to ESTABLISH service
21 ;; connection, then the complete medical history since
22 ;; discharge from military service is required.
23 ;;
24 ;;
25 ;; 2. PRESENT MEDICAL, OCCUPATIONAL, AND SOCIAL HISTORY - over the
26 ;; past one year.
27 ;;
28 ;; a. Frequency, severity, and duration of psychiatric symptoms.
29 ;;
30 ;; b. Length of remissions, to include capacity for adjustment
31 ;; during periods of remissions.
32 ;;
33 ;; c. Extent of time lost from work over the past 12 month
34 ;; period and social impairment. If employed, identify
35 ;; current occupation and length of time at this job. If
36 ;; unemployed, note in complaints whether veteran contends it
37 ;; is due to the effects of a mental disorder. Further
38 ;; indicate following DIAGNOSIS what factors, and objective
39 ;; findings support or rebut that contention.
40 ;;
41 ;; d. Treatments including statement on effectiveness and side
42 ;; effects experienced.
43 ;;
44 ;; 3. SUBJECTIVE COMPLAINTS:
45 ;;
46 ;; a. Describe fully.
47 ;;
48 ;;TOF
49 ;;C. Examination (Objective Findings):
50 ;;
51 ;; Address each of the following and fully describe:
52 ;; 1. Mental status exam to confirm or establish diagnosis in
53 ;; accordance with DSM-IV.
54 ;;
55 ;; 2. Additionally, to allow evaluation by the rating specialist,
56 ;; describe and fully explain the existence, frequency, and
57 ;; extent of the following signs and symptoms, or any others
58 ;; present, and relate how they interfere with employment and
59 ;; social functioning:
60 ;;
61 ;; a. Impairment of thought process or communication.
62 ;;
63 ;;
64 ;; b. Delusions, hallucinations and their persistence.
65 ;;
66 ;;
67 ;; c. Inappropriate behavior cited with examples.
68 ;;
69 ;;
70 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
71 ;;
72 ;;
73 ;; e. Ability to maintain personal hygiene and other basic
74 ;; activities of daily living.
75 ;;
76 ;; f. Orientation to person, place, and time.
77 ;;
78 ;;
79 ;; g. Memory loss or impairment (both short and/or long term).
80 ;;
81 ;;
82 ;; h. Obsessive or ritualistic behavior which interferes with
83 ;; routine activities (describe with examples).
84 ;;
85 ;;
86 ;; i. Rate and flow of speech and note irrelevant, illogical, or
87 ;; obscure speech patterns and whether constant or intermittent.
88 ;;
89 ;;
90 ;; j. Panic attacks noting the severity, duration, frequency and
91 ;; effect on independent functioning and whether clinically
92 ;; observed or good evidence of prior clinical or equivalent
93 ;; observation.
94 ;;
95 ;; k. Depression, depressed mood, or anxiety.
96 ;;
97 ;; l. Impaired impulse control and its effect on motivation or mood.
98 ;;
99 ;;
100 ;; m. Sleep impairment and describe extent it interferes with
101 ;; daytime activities.
102 ;;
103 ;;
104 ;; n. Other symptoms and the extent to which they interfere with
105 ;; activities.
106 ;;
107 ;;
108 ;;D. Diagnostic Tests:
109 ;;
110 ;; 1. Provide psychological testing if deemed necessary.
111 ;; 2. If testing is requested, the results must be reported and
112 ;; considered in arriving at the diagnosis.
113 ;; 3. Provide any specific evaluation information required by the
114 ;; rating board or on BVA Remand (in claims folder).
115 ;;
116 ;; a. COMPETENCY: State whether the veteran is capable of
117 ;; managing his/her benefit payments in the individual's own
118 ;; best interests (a physical disability which prevents the
119 ;; veteran from attending to financial matters in person is
120 ;; not a proper basis for a finding of incompetency unless
121 ;; the veteran is, by reason of that disability, incapable of
122 ;; directing someone else in handling the individual's
123 ;; financial affairs).
124 ;;
125 ;; b. OTHER OPINION: Furnish any other specific opinion requested
126 ;; by the rating board or BVA Remand furnishing the complete
127 ;; rationale and citation of medical texts or treatise
128 ;; supporting opinion, if medical literature review was under-
129 ;; taken. If the requested opinion is medically not ascertainable
130 ;; on exam or testing, please indicate why. If the requested
131 ;; opinion can not be expressed without resorting to
132 ;; speculation or making improbable assumptions say so, and
133 ;; explain why. If the opinion asks "...is it at least as
134 ;; likely as not..?", fully explain the clinical findings and
135 ;; rationale for the opinion.
136 ;;
137 ;; 4. Include results of all diagnostic and clinical tests conducted
138 ;; in the examination report.
139 ;;
140 ;;TOF
141 ;;E. Diagnosis:
142 ;;
143 ;; Provide:
144 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the
145 ;; findings on the examination report.
146 ;; 2. If the diagnosis is changed, explain fully whether the new
147 ;; diagnosis represents a progression of the prior diagnosis or
148 ;; development of a new and separate condition.
149 ;; 3. If there are multiple psychiatric conditions, delineate to the
150 ;; extent possible the symptoms associated with each and a
151 ;; discussion of relationship.
152 ;; 4. Evaluation is based on the effects of the signs and symptoms
153 ;; on occupational and social functioning.
154 ;;
155 ;;NOTE: VA is prohibited by statute from paying compensation for a
156 ;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE,
157 ;;whether based on direct service connection, secondary service connection,
158 ;;or aggravation by a service-connected condition. Therefore, when
159 ;;alcohol or drug abuse accompanies or is associated with another mental
160 ;;disorder, separate, to the extent possible, the effects of the alcohol
161 ;;or drug abuse from the effects of the other mental disorder(s). If it
162 ;;is not possible to separate the effects, explain why.
163 ;;
164 ;;
165 ;;
166 ;;F. Global Assessment of Functioning (GAF):
167 ;;
168 ;;NOTE: The complete multi-axial format as specified by DSM-IV may
169 ;;be required by BVA REMAND or specifically requested by the rating
170 ;;specialist. If so, include the GAF score and note whether it
171 ;;refers to current functioning over the past year, etc.
172 ;;
173 ;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent
174 ;;possible, to provide a GAF score for the service connected conditions
175 ;;alone as well as a separate overall GAF score based on all mental
176 ;;disorders present and explain and discuss the rationale. (See the
177 ;;above note pertaining to alcohol or drug abuse, effects of which cannot
178 ;;be used to assess the effects of a service-connected condition.) If
179 ;;unable to separate symptomatology, explain why.
180 ;;
181 ;;
182 ;;Signature: Date:
183 ;;END
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