| [613] | 1 | DVBCMSCK ;ALB/GTS-557/THM-MUSCLE EXAM ; 5/21/91 9:35 AM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | ;
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| 4 | S PG=1,HD91="Department of Veterans Affairs",HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
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| 5 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 6 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1435 Worksheet" S HD7="MUSCLES (ORTHOPEDIC)",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 7 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 8 | W !!!!,"Narrative:"
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| 9 | F AW=0:1 S AX=$T(TXT+AW) S AY=$P(AX,";;",2) W:AY="$END" !! Q:AY="$END" W ?13,AY,!
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| 10 | I '$D(CMBN) W "A. Medical history:",!!!!!!!!!!,"B. Subjective complaints:",!!!!!!!!!!,"C. Objective findings:",! D HD2
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| 11 | W $S($D(CMBN):"A. ",1:"D. "),"Specific evaluation information required by the rating board",!?4,"(if the information requested is included elsewhere, do not",!?4,"repeat here):",!!!!!
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| 12 | W ?8,"1. Tissue loss comparison -",!!!!!?8,"2. Muscles penetrated -",!!!!!?8,"3. Scar formation measurement (sensitiveness, tenderness) -",!!!!!
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| 13 | W ?8,"4. Adhesions -",!!!!!?8,"5. Damage to tendons -",!!!!!?8,"6. Damage to bones, joints, nerves -",!!!!! D:$D(CMBN) HD2 W ?8,"7. Strength -",!!!!!?8,"8. Evidence of pain -",!!!!!?8,"9. Evidence of muscle hernia -",!!!!!
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| 14 | D:'$D(CMBN) HD2 W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!! D:$Y>50 HD2
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| 15 | W $S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 16 | K LN,LN1,LN2
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| 17 | Q
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| 18 | ;
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| 19 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for "_NAME,!!!
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| 20 | Q
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| 21 | ;
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| 22 | SETIOF ; ** Set device control var's
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| 23 | D HOME^%ZIS
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| 24 | Q
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| 25 | ;
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| 26 | TXT ;;In conducting examinations of muscle damage and functional
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| 27 | ;;impairment the muscles affected by tissue loss, penetrating
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| 28 | ;;injuries, scar formation, adhesions, damage to tendons, or
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| 29 | ;;other factors should be identified individually by the
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| 30 | ;;pathological locations and by motions affected in strength
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| 31 | ;;excursion, and diminished capacity for prolonged use.
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| 32 | ;;
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| 33 | ;;The standard muscle grading system should be used and
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| 34 | ;;is as follows:
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| 35 | ;;
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| 36 | ;;Normal - through full range against normal resistance
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| 37 | ;; Good - full range, less than normal resistance
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| 38 | ;; Fair - full range, gravity only resistance
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| 39 | ;; Poor - full range, gravity and all resistance eliminated
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| 40 | ;;$END
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