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1DVBCWPF1 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ;05/18/2006 11:00am
2 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
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 PTSD:
8 ;;
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
12 ;; of a board certified or board eligible psychiatrist or licensed
13 ;; doctorate-level psychologist;
14 ;; - a psychiatry resident under close supervision of a board certified
15 ;; or board eligible psychiatrist or licensed doctorate-level
16 ;; psychologist; or
17 ;; - a clinical or counseling psychologist completing a one-year internship
18 ;; or residency (for purposes of a doctorate-level degree) under close
19 ;; supervision of a board certified or board eligible psychiatrist or
20 ;; licensed doctorate-level psychologist.
21 ;;
22 ;;A. Identifying Information
23 ;;
24 ;; - age
25 ;; - ethnic background
26 ;; - era of military service
27 ;; - reason for referral (original exam to establish PTSD diagnosis and
28 ;; related psychosocial impairment; re-evaluation of status of existing
29 ;; service-connected PTSD condition)
30 ;;
31 ;;B. Sources of Information
32 ;;
33 ;; - records reviewed (C-file, DD-214, medical records, other documentation)
34 ;; - review of social-industrial survey completed by social worker
35 ;; - statements from collaterals
36 ;; - administration of psychometric tests and questionnaires (identify here)
37 ;;
38 ;;C. Review of Medical Records:
39 ;;
40 ;; 1. Past Medical History:
41 ;;
42 ;; a. Previous hospitalizations and outpatient care.
43 ;; b. Complete medical history is required, including history since
44 ;; discharge from military service.
45 ;; c. Review of Claims Folder is required on initial exams to establish
46 ;; or rule out the diagnosis.
47 ;;
48 ;; 2. Present Medical History - over the past one year.
49 ;;
50 ;; a. Frequency, severity and duration of medical and psychiatric
51 ;; symptoms.
52 ;;TOF
53 ;; b. Length of remissions, to include capacity for adjustment during
54 ;; periods of remissions.
55 ;;
56 ;;D. Examination (Objective Findings):
57 ;; Address each of the following and fully describe:
58 ;;
59 ;; History (Subjective Complaints):
60 ;; Comment on:
61 ;;
62 ;; Premilitary History (refer to social-industrial survey if completed)
63 ;;
64 ;; - describe family structure and environment where raised (identify
65 ;; constellation of family members and quality of relationships)
66 ;; - quality of peer relationships and social adjustment (e.g., activities,
67 ;; achievements, athletic and/or extracurricular involvements, sexual
68 ;; involvements, etc.)
69 ;; - education obtained and performance in school
70 ;; - employment
71 ;; - legal infractions
72 ;; - delinquency or behavior conduct disturbances
73 ;; - substance use and consequences of substance use
74 ;; - significant medical problems and treatments obtained
75 ;; - family psychiatric history
76 ;; - exposure to traumatic stressors (see CAPS trauma assessment checklist)
77 ;; - summary assessment of psychosocial adjustment and progression through
78 ;; developmental milestones (performance in employment or schooling,
79 ;; routine responsibilities of self-care, family role functioning,
80 ;; physical health, social/interpersonal relationship, recreation/leisure
81 ;; pursuits).
82 ;;
83 ;; Military History
84 ;;
85 ;; - branch of service (enlisted or drafted)
86 ;; - dates of service
87 ;; - dates and location of war zone duty and number of months stationed
88 ;; in war zone
89 ;; - Military Occupational Specialty (describe nature and duration of job(s)
90 ;; in war zone)
91 ;; - highest rank obtained during service (rank at discharge if different)
92 ;; - type of discharge from military
93 ;; - substance use and consequences of substance use
94 ;; - combat wounds sustained (describe)
95 ;; - clearly describe the specific stressor event(s) veteran considers
96 ;; particularly traumatic, particularly, if the stressor is a type
97 ;; of personal assault, including sexual assault, provide information,
98 ;; with examples, if possible
99 ;; - indicate overall level of traumatic stress exposure
100 ;; (high, moderate, low) based on frequency and severity of incident
101 ;; exposure
102 ;; - citations or medals received
103 ;; - disciplinary infractions or other adjustment problems during military
104 ;;TOF
105 ;; NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
106 ;; medical evidence establishing a diagnosis of the condition that conforms
107 ;; to the diagnostic criteria of DSM-IV, credible supporting evidence that
108 ;; the claimed in-service stressor actually occurred, and a link, established
109 ;; by medical evidence, between current symptomatology and the claimed
110 ;; in-service stressor. It is the responsibility of the examiner to describe
111 ;; the traumatic stressor leading to PTSD, if he or she makes the diagnosis
112 ;; of PTSD.
113 ;;
114 ;; A diagnosis of PTSD cannot be adequately documented or ruled out without
115 ;; obtaining a detailed military history and reviewing the claims folder.
116 ;; This means that initial review of the folder prior to examination, the
117 ;; history and examination itself, and the dictation for an examination
118 ;; initially establishing PTSD will often require more time than for
119 ;; examinations of other disorders. Ninety minutes to two hours on an
120 ;; initial exam is normal.
121 ;;
122 ;; Post-Military Trauma History (refer to social-industrial survey if
123 ;; completed)
124 ;;
125 ;; - describe post-military traumatic events (see CAPS trauma assessment
126 ;; checklist)
127 ;; - describe psychosocial consequences of post-military trauma exposure(s)
128 ;; (treatment received, disruption to work, adverse health consequences)
129 ;;
130 ;; Post-Military Psychosocial Adjustment (refer to social-industrial survey
131 ;; if completed)
132 ;;
133 ;; - legal history (DWIs, arrests, time spent in jail)
134 ;; - educational accomplishment
135 ;; - employment history (describe periods of unemployment and reasons)
136 ;; - marital and family relationships (including quality of relationships with
137 ;; children)
138 ;; - degree and quality of social relationships
139 ;; - activities and leisure pursuits
140 ;; - substance use and consequences of substance use
141 ;; - significant medical disorders (resulting pain or disability; current
142 ;; medications)
143 ;; - treatment history for significant medical conditions, including
144 ;; hospitalizations
145 ;; - history of inpatient and/or outpatient psychiatric care (dates and
146 ;; conditions treated)
147 ;; - history of assaultiveness
148 ;; - history of suicide attempts
149 ;; - summary statement of current psychosocial functional status (performance
150 ;; in employment or schooling, routine responsibilities of self care,
151 ;; family role functioning, physical health, social/interpersonal
152 ;; relationships, recreation/leisure pursuits).
153 ;;TOF
154 ;;E. Mental Status Examination
155 ;;
156 ;; Conduct a mental status examination aimed at screening for DSM-IV
157 ;; mental disorders. Describe and fully explain the existence, frequency and
158 ;; extent of the following signs and symptoms, or any others present, and
159 ;; relate how they interfere with employment and social functioning:
160 ;;
161 ;; - Impairment of thought process or communication
162 ;; - Delusions, hallucinations and their persistence
163 ;; - Eye Contact, interaction in session, and inappropriate behavior cited
164 ;; with examples
165 ;; - Suicidal or homicidal thoughts, ideations or plans or intent
166 ;; - Ability to maintain minimal personal hygiene and other basic activities
167 ;; of daily living
168 ;; - Orientation to person, place, and time
169 ;; - Memory loss, or impairment (both short and long-term)
170 ;; - Obsessive or ritualistic behavior that interferes with routine activities
171 ;; - Rate and flow of speech and note any irrelevant, illogical, or obscure
172 ;; speech patterns and whether constant or intermittent
173 ;; - Panic attacks noting the severity, duration, frequency, and effect on
174 ;; independent functioning and whether clinically observed or good evidence
175 ;; of prior clinical or equivalent observation is shown
176 ;; - Depression, depressed mood or anxiety
177 ;; - Impaired impulse control and its effect on motivation or mood
178 ;; - Sleep impairment and describe extent it interferes with daytime
179 ;; activities
180 ;; - Other disorders or symptoms and the extent they interfere with activities
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