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1DVBCWME7 ;BPOIFO/RLC - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 12/26/06 2:23pm
2 ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
3 ;Per VHA Directive 10-92-142, this routine should not be modified
4 ;
5TXT ;
6 ;;
7 ;;The following health care providers can perform initial examinations for
8 ;;Mental Disorders:
9 ;;a board-certified or board "eligible" psychiatrist;
10 ;;a licensed doctorate-level psychologist;
11 ;;a doctorate-level mental health provider under the close supervision of a
12 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
13 ;;psychologist;
14 ;;a psychiatry resident under close supervision of a board-certified or
15 ;;board eligible psychiatrist or licensed doctorate-level psychologist; or
16 ;;a clinical or counseling psychologist completing a one-year internship
17 ;;or residency (for purposes of a doctorate-level degree) under close
18 ;;supervision of a board-certified or eligible psychiatrist or licensed
19 ;;doctorate-level psychologist.
20 ;;
21 ;;The following health care providers can perform review examinations for
22 ;;Mental Disorders:
23 ;;a board-certified or board "eligible" psychiatrist;
24 ;;a licensed doctorate-level psychologist;
25 ;;a doctorate-level mental health provider under close supervision of a
26 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
27 ;;psychologist;
28 ;;a psychiatry resident under close supervision of a board-certified or board
29 ;;eligible psychiatrist or licensed doctorate-level psychologist;
30 ;;a clinical or counseling psychologist completing a one-year internship or
31 ;;residency (for purposes of a doctorate-level degree) under close
32 ;;supervision of a board-certified or board eligible psychiatrist or licensed
33 ;;doctorate-level psychologist;
34 ;;a licensed clinical social worker (LCSW); a nurse practitioner, a clinical
35 ;;nurse specialist or physician assistant, if they are clinically privileged
36 ;;to perform activities required for C&P mental disorder examinations, under
37 ;;the close supervision of a board-certified or board eligible psychiatrist
38 ;;or licensed doctorate-level psychologist.
39 ;;
40 ;;A. Review of Medical Records:
41 ;;
42 ;;B. Medical History (Subjective Complaints):
43 ;;
44 ;; Comment on:
45 ;;
46 ;; 1. Past Medical History:
47 ;;
48 ;; a. Previous hospitalizations and outpatient care.
49 ;; b. Medical and occupational history from the time between last rating
50 ;; examination and the present, unless the purpose of this examination
51 ;; is to ESTABLISH service connection, then the complete medical,
52 ;; occupational and social history pre-military, military and since
53 ;; discharge from military service is required.
54 ;; c. Substance use and its consequences.
55 ;;
56 ;; 2. Present Medical, Occupational, and Social History -
57 ;; over the past one year.
58 ;;
59 ;; a. Frequency, severity, and duration of psychiatric symptoms.
60 ;; b. Length of remissions, to include capacity for adjustment during
61 ;; periods of remissions.
62 ;; c. Social functioning and adjustment.
63 ;; d. Extent of time lost from work over the past 12 month period.
64 ;; If employed, identify current occupation and length of time at
65 ;; this job. If unemployed, note in complaints whether veteran
66 ;; contends it is due to the effects of a mental disorder.
67 ;; Further indicate following DIAGNOSIS what factors, and objective
68 ;; findings support or rebut that contention.
69 ;; e. Treatments including statement on effectiveness and side effects
70 ;; experienced.
71 ;;
72 ;; 3. Subjective Complaints:
73 ;;
74 ;; a. Describe fully.
75 ;;
76 ;;C. Examination (Objective Findings):
77 ;;
78 ;; Address each of the following and fully describe:
79 ;;
80 ;; 1. Mental status exam to confirm or establish diagnosis in
81 ;; accordance with DSM-IV.
82 ;; 2. Additionally, to allow evaluation by the rating specialist, describe
83 ;; and fully explain the existence, frequency, and extent of the following
84 ;; signs and symptoms, or any others present, and relate how they interfere
85 ;; with employment and social functioning:
86 ;;
87 ;; a. Impairment of thought process or communication.
88 ;; b. Delusions, hallucinations and their persistence.
89 ;; c. Inappropriate behavior cited with examples.
90 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
91 ;; e. Ability to maintain minimal personal hygiene and other basic
92 ;; activities of daily living.
93 ;; f. Orientation to person, place and time.
94 ;; g. Memory loss or impairment (both short and/or long term).
95 ;; h. Obsessive or ritualistic behavior that interferes with routine
96 ;; activities.
97 ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
98 ;; speech patterns and whether constant or intermittent.
99 ;; j. Panic attacks noting the severity, duration, frequency and effect
100 ;; on independent functioning and whether clinically observed or good
101 ;; evidence of prior clinical or equivalent observation.
102 ;; k. Depression, depressed mood, or anxiety.
103 ;; l. Impaired impulse control and its effect on motivation or mood.
104 ;; m. Sleep impairment and describe extent it interferes with daytime
105 ;; activities.
106 ;; n. Other symptoms and the extent to which they interfere with
107 ;; activities.
108 ;;
109 ;;D. Diagnostic Tests:
110 ;;
111 ;; 1. Provide psychological testing if deemed necessary.
112 ;; 2. If testing is requested, the results must be reported and considered in
113 ;; arriving at the diagnosis.
114 ;; 3. Provide any specific evaluation information required by the rating board
115 ;; or on BVA Remand (in claims folder).
116 ;;
117 ;; a. CAPACITY TO MANAGE FINANCIAL AFFAIRS Mental competency, for
118 ;; VA benefits purposes, refers only to the ability of the veteran
119 ;; to manage VA benefit payments in his or her own best interest,
120 ;; and not to any other subject. Mental incompetence, for VA benefits
121 ;; purposes, means that the veteran, because of injury or disease,
122 ;; is not capable of managing benefit payments in his or her best
123 ;; interest. In order to assist raters in making a legal determination
124 ;; as to competency, please address the following:
125 ;; - What is the impact of injury or disease on the veteran's ability
126 ;; to manage his or her financial affairs, including consideration
127 ;; of such things as knowing the amount of his or her VA benefit
128 ;; payment, knowing the amounts and types of bills owed monthly,
129 ;; and handling the payment prudently? Does the veteran handle
130 ;; the money and pay the bills?
131 ;;
132 ;; - Based on your examination, do you believe that the veteran is
133 ;; capable of managing his or her financial affairs?
134 ;; - Please provide examples to support your conclusion.
135 ;;
136 ;; If you believe a Social Work Service assessment is needed before
137 ;; you can give your opinion on the veteran's ability to manage his
138 ;; or her financial affairs, please explain why.
139 ;;
140 ;; b. Other Opinion: Furnish any other specific opinion requested
141 ;; by the rating board or BVA Remand furnishing the complete
142 ;; rationale and citation of medical texts or treatise supporting
143 ;; opinion, if medical literature review was undertaken.
144 ;; If the requested opinion is medically not ascertainable on exam
145 ;; or testing, please indicate why. If the requested opinion cannot
146 ;; be expressed without resorting to speculation or making improbable
147 ;; assumptions say so, and explain why. If the opinion asks "...is it
148 ;; at least as likely as not..?", fully explain the clinical findings
149 ;; and rationale for the opinion.
150 ;;
151 ;; 4. Include results of all diagnostic and clinical tests conducted
152 ;; in the examination report.
153 ;;
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