source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWME1.m@ 724

Last change on this file since 724 was 613, checked in by George Lilly, 15 years ago

initial load of WorldVistAEHR

File size: 7.2 KB
Line 
1DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
2 ;;2.7;AMIE;**34**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;; Comment on:
10 ;;
11 ;; 1. Past Medical History:
12 ;;
13 ;; a. Previous hospitalizations and outpatient care.
14 ;; b. Medical and occupational history from the time between last rating
15 ;; examination and the present, UNLESS the purpose of this examination
16 ;; is to ESTABLISH service connection, then the complete medical history
17 ;; since discharge from military service is required.
18 ;;
19 ;; 2. Present Medical, Occupational, and Social History -
20 ;; over the past one year.
21 ;;
22 ;; a. Frequency, severity, and duration of psychiatric symptoms.
23 ;; b. Length of remissions, to include capacity for adjustment during
24 ;; periods of remissions.
25 ;; c. Extent of time lost from work over the past 12 month period and
26 ;; social impairment. If employed, identify current occupation and
27 ;; length of time at this job. If unemployed, note in Complaints whether
28 ;; veteran contends it is due to the effects of a mental disorder.
29 ;; Further indicate following DIAGNOSIS what factors, and objective
30 ;; findings support or rebut that contention.
31 ;; d. Treatments including statement on effectiveness and side effects
32 ;; experienced.
33 ;;
34 ;; 3. Subjective Complaints:
35 ;;
36 ;; a. Describe fully.
37 ;;
38 ;;C. Examination (Objective Findings):
39 ;; Address each of the following and fully describe:
40 ;;
41 ;; 1. Mental status exam to confirm or establish diagnosis in
42 ;; accordance with DSM-IV.
43 ;; 2. Additionally, to allow evaluation by the rating specialist, describe
44 ;; and fully explain the existence, frequency, and extent of the following
45 ;; signs and symptoms, or any others present, and relate how they interfere
46 ;; with employment and social functioning:
47 ;; a. Impairment of thought process or communication.
48 ;; b. Delusions, hallucinations and their persistence.
49 ;; c. Inappropriate behavior cited with examples.
50 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
51 ;; e. Ability to maintain minimal personal hygiene and other basic
52 ;; activities of daily living.
53 ;; f. Orientation to person, place and time.
54 ;; g. Memory loss or impairment (both short and/or long term).
55 ;; h. Obsessive or ritualistic behavior which interferes with routine
56 ;; activities (describe with examples).
57 ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
58 ;; speech patterns and whether constant or intermittent.
59 ;; j. Panic attacks noting the severity, duration, frequency and effect
60 ;; on independent functioning and whether clinically observed or good
61 ;; evidence of prior clinical or equivalent observation.
62 ;; k. Depression, depressed mood, or anxiety.
63 ;; l. Impaired impulse control and its effect on motivation or mood.
64 ;; m. Sleep impairment and describe extent it interferes with daytime
65 ;; activities.
66 ;; n. Other symptoms and the extent to which they interfere with
67 ;; activities.
68 ;;
69 ;;D. Diagnostic Tests:
70 ;; 1. Provide psychological testing if deemed necessary.
71 ;; 2. If testing is requested, the results must be reported and considered in
72 ;; arriving at the diagnosis.
73 ;; 3. Provide any specific evaluation information required by the rating board
74 ;; or on BVA Remand (in claims folder).
75 ;;
76 ;; a. COMPETENCY: State whether the veteran is capable of managing
77 ;; his/her benefit payments in the individual's own best interests
78 ;; (a physical disability which prevents the veteran from attending
79 ;; to financial matters in person is not a proper basis for a finding
80 ;; of incompetency unless the veteran is, by reason of that
81 ;; disability, incapable of directing someone else in handling
82 ;; the individual's financial affairs).
83 ;;
84 ;; b. OTHER OPINION: Furnish any other specific opinion requested
85 ;; by the rating board or BVA Remand furnishing the complete
86 ;; rationale and citation of medical texts or treatise supporting
87 ;; opinion, if medical literature review was undertaken.
88 ;; If the requested opinion is medically not ascertainable on exam
89 ;; or testing, please indicate WHY. If the requested opinion can not
90 ;; be expressed without resorting to speculation or making improbable
91 ;; assumptions say so, and explain why. If the opinion asks "...is it
92 ;; at least as likely as not..?", fully explain the clinical findings
93 ;; and rationale for the opinion.
94 ;; 4. Include results of all diagnostic and clinical tests conducted
95 ;; in the examination report.
96 ;;TOF
97 ;;E. Diagnosis:
98 ;; Provide:
99 ;;
100 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
101 ;; on the examination report.
102 ;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
103 ;; represents a progression of the prior diagnosis or development of a new
104 ;; and separate condition.
105 ;; 3. If there are multiple mental disorders, delineate to the extent possible
106 ;; the symptoms associated with each and a discussion of relationship.
107 ;; 4. Evaluation is based on the effects of the signs and symptoms on
108 ;; occupational and social functioning.
109 ;;
110 ;;NOTE: VA is prohibited by statute from paying compensation for a disability
111 ;;that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on
112 ;;direct service connection, secondary service connection, or aggravation by
113 ;;a service-connected condition. Therefore, when alcohol or drug abuse
114 ;;accompanies or is associated with another mental disorder, separate, to
115 ;;the extent possible, the effects of the alcohol or drug abuse from the effects
116 ;;of the other mental disorder(s). If it is not possible to separate the effects,
117 ;;explain why.
118 ;;
119 ;;F. Global Assessment of Functioning (GAF):
120 ;;
121 ;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
122 ;;by BVA REMAND or specifically requested by the rating specialist. If so,
123 ;;include the GAF score and note whether it refers to current functioning.
124 ;;A BVA REMAND may also request , in addition to an overall GAF score, that a
125 ;;separate GAF score be provided for each mental disorder present when there are
126 ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
127 ;;If separate GAF scores can be given, an explanation and discussion of
128 ;;the rationale is needed. If it is not possible, an explanation as to why not is
129 ;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
130 ;; which cannot be used to assess the effects of a service-connected condition.)
131 ;;
132 ;;
133 ;;Signature: Date:
134 ;;END
Note: See TracBrowser for help on using the repository browser.