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1DVBCWPG1 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ;05/18/2006 12:00pm
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 review 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 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 psychologist;
16 ;; - a clinical or counseling psychologist completing a one year internship
17 ;; or residency (for the purposes of a doctorate-level degree) under
18 ;; close supervision of a board certified or board eligible psychiatrist
19 ;; or licensed doctorate-level psychologist;
20 ;; - a licensed clinical social worker (LCSW), a nurse practitioner,
21 ;; a clinical nurse specialist, or a physician assistant, if they are
22 ;; clinically privileged to perform activities required for C&P mental
23 ;; disorder examinations, under close supervision of a board certified
24 ;; or board eligible psychiatrist or doctorate-level psychologist.
25 ;;
26 ;;A. Review of Medical Records
27 ;;
28 ;;B. Medical History since last exam:
29 ;;
30 ;; Comment on:
31 ;;
32 ;; 1. Hospitalizations and outpatient care from the time between last
33 ;; rating examination to the present, UNLESS the purpose of this
34 ;; examination is to ESTABLISH service connection, then the complete
35 ;; medical history since discharge from military service is required.
36 ;; 2. Significant medical disorders (resulting pain or disability; current
37 ;; medications).
38 ;; 3. Frequency, severity and duration of psychiatric symptoms.
39 ;; 4. Length of remissions from psychiatric symptoms, to include capacity
40 ;; for adjustment during periods of remissions.
41 ;; 5. Treatments including statement on effectiveness and side effects
42 ;; experienced.
43 ;; 6. Subjective Complaints: Describe fully.
44 ;;
45 ;;C. Psychosocial Adjustment since the last exam
46 ;;
47 ;; - legal history (DWIs, arrests, time spent in jail)
48 ;; - educational accomplishment
49 ;;TOF
50 ;; - extent of time lost from work over the past 12 month period and social
51 ;; impairment. If employed, identify current occupation and length of time
52 ;; at this job. If unemployed, note in complaints whether veteran contends
53 ;; it is due to the effects of a mental disorder. Further indicate following
54 ;; DIAGNOSIS what factors, and objective findings support or rebut that
55 ;; contention.
56 ;; - marital and family relationships (including quality of relationships
57 ;; with spouse and children)
58 ;; - degree and quality of social relationships
59 ;; - activities and leisure pursuits
60 ;; - substance use and consequences of substance us
61 ;; medications)
62 ;; - history of violence/assaultiveness
63 ;; - history of suicide attempts
64 ;; - summary statement of current psychosocial functional status (performance
65 ;; in employment or schooling, routine responsibilities of self care,
66 ;; family role functioning, physical health, social/interpersonal
67 ;; relationship, recreation/leisure pursuits)
68 ;;
69 ;;D. Mental Status Examination
70 ;;
71 ;; Conduct a mental status examination aimed at screening for DSM-IV
72 ;; mental disorders. Describe and fully explain the existence, frequency and
73 ;; extent of the following signs and symptoms, or any others present, and
74 ;; relate how they interfere with employment and social functioning:
75 ;;
76 ;; - Impairment of thought process or communication
77 ;; - Delusions, hallucinations and their persistence
78 ;; - Eye Contact, interaction in session, and inappropriate behavior cited
79 ;; with examples
80 ;; - Suicidal or homicidal thoughts, ideations or plans or intent
81 ;; - Ability to maintain minimal personal hygiene and other basic activities
82 ;; of daily living
83 ;; - Orientation to person, place, and time
84 ;; - Memory loss, or impairment (both short and long-term)
85 ;; - Obsessive or ritualistic behavior that interferes with routine activities
86 ;; - Rate and flow of speech and note any irrelevant, illogical, or obscure
87 ;; speech patterns and whether constant or intermittent
88 ;; - Panic attacks noting the severity, duration, frequency, and effect on
89 ;; independent functioning and whether clinically observed or good evidence
90 ;; of prior clinical or equivalent observation is shown
91 ;; - Depression, depressed mood or anxiety
92 ;; - Impaired impulse control and its effect on motivation or mood
93 ;; - Sleep impairment and describe extent it interferes with daytime
94 ;; activities
95 ;; - Other disorders or symptoms and the extent they interfere with
96 ;; activities
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