source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPE1.m

DVBCWPE1 ;ESW/ PTSD WKS TEXT - 1 ; 9 Oct 2000
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;
 ;;A. Review of Medical Records
 ;;
 ;;B. Medical History since last exam:
 ;;     Comments on:
 ;;
 ;;     1. Hospitalizations and outpatient care from the time between last
 ;;        rating examination to the present, UNLESS the purpose of this 
 ;;        examination is to ESTABLISH service connection, then the complete
 ;;        medical history since discharge from military service is required.
 ;;     2. Frequency, severity and duration of psychiatric symptoms.
 ;;     3. Length of remissions from psychiatric symptoms, to include capacity
 ;;        for adjustment during periods of remissions.
 ;;     4. Treatments including statement on effectiveness and side effects
 ;;        experienced.
 ;;     5. SUBJECTIVE COMPLAINTS: Describe fully.
 ;;
 ;;C. Psychosocial Adjustment since the last exam
 ;;
 ;;   * legal history (DWIs, arrests, time spent in jail)
 ;;   * educational accomplishment
 ;;   * extent of time list from work over the past 12 month period and social
 ;;     impairment. If employed, identify current occupation and length of time
 ;;     at this job.
 ;;       If unemployed, note in COMPLAINTS whether veteran contends it is due to
 ;;       the effects of a mental disorder. Further indicate following DIAGNOSIS
 ;;       what factors, and objective findings support or rebut that contention.
 ;;   * marital and family relationships ( including quality of relationships with
 ;;     spouse and children)
 ;;   * degree and quality of social relationships
 ;;   * activities and leisure pursuits
 ;;   * problematic substance abuse
 ;;   * significant medical disorders (resulting pain or disability; current
 ;;     medications)
 ;;   * history of violence/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
 ;;     relationship, recreation/leisure pursuits)
 ;;TOF
 ;;D. Mental Status Examination
 ;;
 ;;   Conduct a BRIEF mental status examinaton 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 disorders
 ;;     - personality disorders (especially antisocial personality disorder
 ;;       and borderline personality disorder)
 ;;