| 1 | DVBCWPG3 ;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 | ; | 
|---|
| 5 | TXT ; | 
|---|
| 6 | ;; | 
|---|
| 7 | ;;M.  Effects of PTSD on Occupational and Social Functioning | 
|---|
| 8 | ;; | 
|---|
| 9 | ;;Evaluation of PTSD is based on its effects on occupational and social | 
|---|
| 10 | ;;functioning.  Select the appropriate assessment of the veteran from the | 
|---|
| 11 | ;;choices below: | 
|---|
| 12 | ;; | 
|---|
| 13 | ;;   - Total occupational and social impairment due to PTSD signs and symptoms. | 
|---|
| 14 | ;; | 
|---|
| 15 | ;;     Provide examples and pertinent symptoms, including those already reported. | 
|---|
| 16 | ;; | 
|---|
| 17 | ;;                           OR | 
|---|
| 18 | ;; | 
|---|
| 19 | ;;   - PTSD signs and symptoms result in deficiencies in most of the following | 
|---|
| 20 | ;;     areas: | 
|---|
| 21 | ;;     work, school, family relations, judgment, thinking, and mood. | 
|---|
| 22 | ;; | 
|---|
| 23 | ;;     Provide examples and pertinent symptoms, including those already | 
|---|
| 24 | ;;     reported for each affected area. | 
|---|
| 25 | ;;TOF | 
|---|
| 26 | ;;                           OR | 
|---|
| 27 | ;; | 
|---|
| 28 | ;;   - There is reduced reliability and productivity due to PTSD signs and | 
|---|
| 29 | ;;     symptoms. | 
|---|
| 30 | ;; | 
|---|
| 31 | ;;     Provide examples and pertinent symptoms, including those already reported. | 
|---|
| 32 | ;; | 
|---|
| 33 | ;;                           OR | 
|---|
| 34 | ;; | 
|---|
| 35 | ;;   - There is occasional decrease in work efficiency or there are intermittent | 
|---|
| 36 | ;;     periods of inability to perform occupational tasks due to signs and | 
|---|
| 37 | ;;     symptoms, but generally satisfactory functioning (routine behavior, | 
|---|
| 38 | ;;     self-care, and conversation normal). | 
|---|
| 39 | ;; | 
|---|
| 40 | ;;     Provide examples and pertinent symptoms, including those already reported. | 
|---|
| 41 | ;; | 
|---|
| 42 | ;;                           OR | 
|---|
| 43 | ;; | 
|---|
| 44 | ;;   - There are PTSD signs and symptoms that are transient or mild and | 
|---|
| 45 | ;;     decrease work efficiency and ability to perform occupational tasks | 
|---|
| 46 | ;;     only during periods of significant stress. | 
|---|
| 47 | ;; | 
|---|
| 48 | ;;     Provide examples and pertinent symptoms, including those already reported. | 
|---|
| 49 | ;; | 
|---|
| 50 | ;;                           OR | 
|---|
| 51 | ;; | 
|---|
| 52 | ;;   - PTSD symptoms require continuous medication. | 
|---|
| 53 | ;; | 
|---|
| 54 | ;;                           OR | 
|---|
| 55 | ;; | 
|---|
| 56 | ;;   - Select all that apply. | 
|---|
| 57 | ;;   - PTSD symptoms are not severe enough to require continuous medication. | 
|---|
| 58 | ;;   - PTSD symptoms are not severe enough to interfere with occupational | 
|---|
| 59 | ;;     and social functioning. | 
|---|
| 60 | ;; | 
|---|
| 61 | ;; | 
|---|
| 62 | ;;   Include your name; your credentials, (i.e., board certified psychiatrist, | 
|---|
| 63 | ;;   licensed psychologist, psychiatry resident or psychology intern, | 
|---|
| 64 | ;;   LCSW, or NP); circumstances under which you performed the examination, | 
|---|
| 65 | ;;   if applicable (i.e., under the close supervision of an attending | 
|---|
| 66 | ;;   psychiatrist or psychologist); name of supervising psychiatrist or | 
|---|
| 67 | ;;   psychologist, if applicable. | 
|---|
| 68 | ;; | 
|---|
| 69 | ;; | 
|---|
| 70 | ;;Signature:                                               Date: | 
|---|
| 71 | ;; | 
|---|
| 72 | ;; | 
|---|
| 73 | ;;Signature of Supervising | 
|---|
| 74 | ;;psychiatrist or psychologist:                            Date: | 
|---|
| 75 | ;;END | 
|---|