source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPE4.m@ 794

DVBCWPE4 ;BP-CIOFO/MM - REVIEW PTSD WORKSHEET TEXT ;3/27/2002
 ;;2.7;AMIE;**43**;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
 ;;
 ;;   1. legal history (DWIs, arrests, time spent in jail)
 ;;   2. educational accomplishment
 ;;   3. extent of time lost 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.
 ;;   4. marital and family relationships ( including quality of relationships with
 ;;      spouse and children)
 ;;   5. degree and quality of social relationships
 ;;   6. activities and leisure pursuits
 ;;   7. problematic substance abuse
 ;;   8. significant medical disorders (resulting pain or disability; current
 ;;      medications)
 ;;   9. history of violence/assaultiveness
 ;;  10. history of suicide attempts
 ;;  11. 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 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:
 ;;
 ;;   1. Impairment of thought process or communication.
 ;;   2. Delusions, hallucinations and their persistence.
 ;;   3. Eye Contact, interaction in session, and inappropriate behavior cited
 ;;      with examples.
 ;;   4. Suicidal or homicidal thoughts, ideations or plans or intent.
 ;;   5. Ability to maintain minimal personal hygiene and other basic activities
 ;;      of daily living.
 ;;   6. Orientation to person, place, and time.
 ;;   7. Memory loss, or impairment (both short and long-term).
 ;;   8. Obsessive or ritualistic behavior which interferes with routine activities
 ;;      and describe any found.
 ;;   9. Rate and flow of speech and note any irrelevant, illogical, or obscure
 ;;      speech patterns and whether constant or intermittent.
 ;;  10. 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.
 ;;  11. Depression, depressed mood or anxiety.
 ;;  12. Impaired impulse control and its effect on motivation or mood.
 ;;  13. Sleep impairment and describe extent it interferes with daytime activities.
 ;;  14. Other disorders or symptoms and the extent they interfere with activities,
 ;;      particularly:
 ;;
 ;;     a. mood disorders (especially major depression and dysthymia)
 ;;     b. substance use disorders (especially alcohol use disorders)
 ;;     c. anxiety disorders (especially panic disorder, obsessive-compulsive
 ;;        disorder, generalized anxiety disorder)
 ;;     d. somatoform disorders
 ;;     e. personality disorders (especially antisocial personality disorder
 ;;        and borderline personality disorder)
 ;;