source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPT1.m@ 1094

DVBCWPT1 ;ALB/CMM PTSD WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;Narrative:  Service connection for post-traumatic stress disorder (PTSD) 
 ;;requires medical evidence establishing a clear diagnosis of the 
 ;;condition, credible supporting evidence that the claimed in-service 
 ;;stressor actually occurred, and a link, established by medical 
 ;;evidence, between current symptomatology and the claimed in-service 
 ;;stressor.  It is the responsibility of the examiner to indicate the 
 ;;extreme traumatic stressor leading to PTSD, if he or she makes the 
 ;;diagnosis of PTSD.  It is the responsibility of the rating specialist
 ;;to confirm that the cited stressor occurred during active duty.
 ;;
 ;;A diagnosis of PTSD cannot be adequately documented or ruled out 
 ;;without obtaining a detailed military history and reviewing the 
 ;;claims folder.  This means that initial review of the folder prior to
 ;;examination, the history and examination itself, and the dictation for
 ;;an examination initially establishing PTSD will often require more 
 ;;time than examinations of other disorders.  Ninety minutes to two 
 ;;hours on an initial exam is normal.
 ;;
 ;;A.  Review or Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1. PAST MEDICAL HISTORY:
 ;;
 ;;       a. Previous hospitalizations and outpatient care.
 ;;
 ;; 
 ;;       b. Medical and occupational history (from the time between last
 ;;          rating examination and the present) needs to be accounted 
 ;;          for, UNLESS the purpose of this examination is to ESTABLISH
 ;;          service connection, then a complete medical history 
 ;;          including description of stressors and history since 
 ;;          discharge from military service is required.
 ;;
 ;; 
 ;;       c. Review of Claims Folder is also required on initial exams 
 ;;          to establish or rule out the diagnosis.
 ;;
 ;;
 ;;
 ;;    2. PRESENT MEDICAL, OCCUPATIONAL AND SOCIAL HISTORY - over the 
 ;;       past one year.
 ;; 
 ;;       a.  Frequency, severity, and duration of psychiatric symptoms.
 ;;
 ;;
 ;;       b.  Length of remissions, to include capacity for adjustment 
 ;;           during periods of remissions.
 ;;
 ;;
 ;;       c.  Extent of social impairment and time lost from work over 
 ;;           the past 12-month period.  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 discuss in 
 ;;           DIAGNOSIS what factors and objective findings support or 
 ;;           rebut that contention.
 ;;
 ;;
 ;;    3. SUBJECTIVE COMPLAINTS:
 ;;
 ;;        a. Describe fully.
 ;;
 ;;
 ;;C.  Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe:
 ;;    1. Stressor information:  Clearly describe the stressor. 
 ;;       Particularly if the stressor is a type of personal assault, 
 ;;       including sexual assault, provide information, with examples, 
 ;;       if possible, on behavioral, cognitive, social, or affective 
 ;;       changes that the veteran links to the stressor.  Include 
 ;;       information on related somatic symptoms.  If there is a
 ;;       history of multiple stressors, assess the impact of each, to 
 ;;       the extent possible.
 ;;  
 ;;
 ;;    2. Mental status exam to confirm or establish diagnosis in 
 ;;       accordance with DSM-IV:
 ;; 
 ;; 
 ;;       a. Are all diagnostic criteria to establish a diagnosis for 
 ;;          309.81, Post Traumatic Stress Disorder, as specified in 
 ;;          DSM-IV, fully met?
 ;;
 ;;
 ;; 
 ;;       b. For initial examination to establish service connection, 
 ;;          fully discuss the criteria in steps A through F supporting 
 ;;          or ruling out the diagnosis.
 ;; 
 ;; 
 ;;       c. Describe any associated symptoms.
 ;; 
 ;; 
 ;;       d. Specify onset and duration of symptoms as acute, chronic, or
 ;;          with delayed onset.
 ;; 
 ;; 
 ;;    3. Describe in detail the linkage between the stressor and the 
 ;;       current symptoms and clinical findings.
 ;; 
 ;; 
 ;;    4. 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:
 ;;
 ;;       a. Impairment of thought process or communication.
 ;; 
 ;; 
 ;;       b. Delusions, hallucinations and their persistence.
 ;;  
 ;; 
 ;;       c. Inappropriate behavior cited with examples.
 ;; 
 ;; 
 ;;       d. Suicidal or homicidal thoughts, ideations or plans or intent.
 ;; 
 ;; 
 ;;       e. Ability to maintain minimal personal hygiene and other basic
 ;;          activities of daily living.
 ;; 
 ;; 
 ;;       f. Orientation to person, place, and time.
 ;; 
 ;; 
 ;;       g. Memory loss, or impairment (both short and long-term).
 ;; 
 ;; 
 ;;       h. Obsessive or ritualistic behavior which interferes with 
 ;;          routine activities and describe any found.
 ;; 
 ;; 
 ;;       i. Rate and flow of speech and note any irrelevant, illogical,
 ;;          or obscure speech patterns and whether constant or intermittent.
 ;; 
 ;; 
 ;;       j. 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.
 ;; 
 ;; 
 ;;       k. Depression, depressed mood or anxiety.
 ;; 
 ;; 
 ;;       l. Impaired impulse control and its effect on motivation or mood.
 ;; 
 ;; 
 ;;       m. Sleep impairment and describe extent it interferes with 
 ;;          daytime activities.
 ;; 
 ;; 
 ;;       n. Other symptoms and the extent they interfere with activities.
 ;;
 ;;
 ;;D. Diagnostic Tests:
 ;;
 ;;   1. Provide psychological testing if deemed necessary.
 ;;   2. If testing is requested, the results must be considered in 
 ;;      arriving at the diagnosis.
 ;;   3. Provide specific evaluation information required by the rating 
 ;;      board or on a BVA Remand.
 ;; 
 ;;      a. COMPETENCY:  State whether the veteran is capable of managing
 ;;         his or her benefit payments in the individual's own best 
 ;;         interests.  (A physical disability which prevents the veteran
 ;;         from attending to financial matters in person is not a proper
 ;;         basis for a finding of incompetence unless the veteran is, by
 ;;         reason of that disability, incapable of directing someone 
 ;;         else in handling the individual's financial affairs.)
 ;; 
 ;;      b. OTHER OPINION:  Furnish any other specific opinion requested
 ;;         by the rating board or BVA remand, furnishing the complete 
 ;;         rationale and citation of medical texts or treatise supporting 
 ;;         opinion, if medical literature review was undertaken.  If the
 ;;         requested opinion is medically not ascertainable on exam or 
 ;;         testing, please state why. If the requested opinion cannot be
 ;;         expressed without resorting to speculation or making 
 ;;         improbable assumptions, say so and explain why.  If the 
 ;;         opinion asks " ... is it at least as likely as not ... ", 
 ;;         fully explain the clinical findings and rationale for the 
 ;;         opinion.
 ;;
 ;;     4.  Include results of all diagnostic and clinical tests 
 ;;         conducted in the examination report.
 ;; 
 ;;