source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPD1.m@ 1671

DVBCWPD1 ;ALB/ESW PTSD WKS TEXT - 1 ; 1/17/01 3:16pm
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
TXT ;
 ;;
 ;;A. Identifying Information
 ;;
 ;;- age
 ;;- ethnic background
 ;;- era of military service
 ;;- reason for referral (original exam to establish PTSD diagnosis and related
 ;;  psychosocial impairment; re-evaluation of status of existing service-
 ;;  connected PTSD condition)
 ;;
 ;;B. Sources of Information
 ;;
 ;;   * records reviewed (C-file, DD-214, medical records, other documentation)
 ;;   * review of social-industrial survey completed by social worker
 ;;   * statements from collaterals
 ;;   * administration of psychometric tests and questionnaires (identify here)
 ;; 
 ;;C. Review of Medical Records:
 ;;1. Past Medical History:
 ;;
 ;;   a. Previous hospitalizations and outpatient care.
 ;;   b. Complete medical history is required, including history since discharge
 ;;      from military service.
 ;;   c. Review of Claims Folder is required on initial exams to establish or
 ;;      rule out the diagnosis.
 ;;
 ;;2. Present Medical History - over the past one year.
 ;;
 ;;   a. Frequency,severity and duration of medical and psychiatric symptoms.
 ;;   b. Length of remissions, to include capacity for adjustment during periods
 ;;      of remissions.
 ;;
 ;;D. Examination (Objective Findings):
 ;;    Address each of the following and fully describe:
 ;;
 ;;    History (Subjective Complaints):
 ;;     Comment on:
 ;;
 ;;       Preliminary History (refer to social-industrial survey if completed)
 ;;
 ;;       * describe family structure and environment where raised (identify
 ;;         constellation of family members and quality of relationships)
 ;;TOF
 ;;       * quality of peer relationships and social adjustment (e.g., activities,
 ;;         achievements, athletic and/or extracurricular involvements, sexual
 ;;         involvement, etc.)
 ;;       * education obtained and performance in school
 ;;       * employment
 ;;       * legal infractions
 ;;       * delinquency or behavior conduct disturbances
 ;;       * substance use patterns
 ;;       * significant medical problems and treatments obtained
 ;;       * family psychiatric history
 ;;       * exposure to traumatic stressors (see CAPS trauma assessment checklist)
 ;;       * summary assessment of psychosocial adjustment and progression through
 ;;         developmental milestones (performance in employment or schooling,
 ;;         routine responsibilities of self-care, family role functioning,
 ;;         physical health, social/interpersonal relationship, recreation/leisure
 ;;         pursuits).
 ;;
 ;;       Military History
 ;;
 ;;       * branch of service (enlisted or drafted)
 ;;       * dates of service
 ;;       * dates and location of war zone duty and number of months stationed
 ;;         in war zone
 ;;       * Military Occupational Specialty (describe nature and duration of job(s)
 ;;         in war zone
 ;;       * highest rank obtained during service ( rank at discharge if different)
 ;;       * type of discharge from military
 ;;       * describe routine combat stressors veterans was exposed to
 ;;        (refer to Combat Scale)
 ;;       * combat wounds sustained (describe)
 ;;       * CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED
 ;;         PARTICULARLY TRAUMATIC.
 ;;         Clearly describe the stressor. Particularly if the stressor is a type
 ;;         of personal assault, including sexual assault, provide information,
 ;;         with examples, if possible.
 ;;       * indicate overall level of traumatic stress exposure
 ;;         (high, moderate,low) based on frequency and severity of incident
 ;;         exposure
 ;;       * citations or medals received
 ;;       * disciplinary infractions or other adjustment problems during military
 ;;
 ;;NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
 ;;medical evidence establishing a clear diagnosis of the condition that conforms
 ;;to the diagnostic criteria of DSM-IV, credible supporting evidence that
 ;;the claimed in-service stressor actually occurred, and a link, established by
 ;;medical evidence, between current symptomatology and the claimed in-service 
 ;;stressor. It is the responsibility of the examiner to indicate the traumatic
 ;;stressor leading to PTSD, if he or she makes the diagnosis of PTSD.
 ;;  Crucial in this description are specific details of the stressor, with names,
 ;;  dates, and places linked to the stressor, so that the rating specialist can
 ;;  confirm that the cited stressor occurred during active duty.
 ;;
 ;;A diagnosis of PTSD cannot be adequately documented or ruled out without
 ;;obtaining a detailed military history and reviewing the claims folder. 
 ;;This means that initial review of the folder prior to examination, the history
 ;;and examination itself, and the dictation for an examination initially
 ;;establishing PTSD will often require more time than for examinations of other
 ;;disorders.
 ;;
 ;;   Post-Military Trauma History (refer to social-industrial survey if completed)
 ;;
 ;;   * describe post-military traumatic events (see CAPS trauma assessment
 ;;     checklist)
 ;;   * describe psychosocial consequences of post-military trauma exposure(s)
 ;;     (treatment received, disruption to work, adverse health consequences)
 ;;
 ;;   Post-Military Psychosocial Adjustment ( refer to social-industrial survey
 ;;   if completed)
 ;;
 ;;   * legal history (DWIs, arrests, time spent in jail)
 ;;   * educational accomplishment
 ;;   * employment history (describe periods of employment and reasons)
 ;;   * marital and family relationships ( including quality of relationships with
 ;;     children)
 ;;   * degree and quality of social relationships
 ;;   * activities and leisure pursuits
 ;;   * problematic substance abuse (lifetime and current)
 ;;   * significant medical disorders (resulting pain or disability; current
 ;;     medications)
 ;;   * treatment history for significant medical conditions, including 
 ;;     hospitalizations
 ;;   * history of inpatient and/or outpatient psychiatric care (dates and
 ;;     conditions treated)
 ;;   * history of 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
 ;;     relationships, recreation/leisure pursuits)
 ;;
 ;;E. Mental Status Examination
 ;;
 ;;   Conduct a BRIEF 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 which interferes with routine activities
 ;;     and describe any found.
 ;;   * 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,
 ;;     particularly:
 ;;
 ;;     - mood disorders ( especially major depression and dysthymia)
 ;;     - substance use disorders (especially alcohol use disorders)
 ;;     - anxiety disorders (especially panic disorder, obsessive-compulsive
 ;;       disorder, generalized anxiety disorder)
 ;;     - somatoform disorder
 ;;     - personality disorders (especially antisocial personality disorder
 ;;       and borderline personality disorder)
 ;;
 ;;Specify onset and duration of symptoms as acute, chronic, or with delayed onset.