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1DVBCWME5 ;BPOIFO/ESW - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 10/1/02 5:39pm
2 ;;2.7;AMIE;**46**;Apr 10, 1995
3 ;Per VHA Directive 10-92-142, this routine should not be modified
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 ;;
71 ;; 1. Provide psychological testing if deemed necessary.
72 ;; 2. If testing is requested, the results must be reported and considered in
73 ;; arriving at the diagnosis.
74 ;; 3. Provide any specific evaluation information required by the rating board
75 ;; or on BVA Remand (in claims folder).
76 ;;
77 ;; a. CAPACITY TO MANAGE FINANCIAL AFFAIRS
78 ;;
79 ;; Mental competency, for VA benefits purposes, refers only to
80 ;; the ability of the veteran to manage VA benefit payments in his or
81 ;; her own best interest, and not to any other subject. Mental
82 ;; incompetency, for VA benefits purposes, means that the veteran,
83 ;; because of injury or disease, is not capable of managing benefit
84 ;; payments in his or her best interest. In order to assist raters in
85 ;; making a legal determination as to competency,
86 ;; please address the following:
87 ;; What is the impact of injury or disease on the veteran's ability
88 ;; to manage his or her financial affairs, including consideration
89 ;; of such things as knowing the amount of his or her VA benefit
90 ;; payment, knowing the amounts and types of bills owed monthly,
91 ;; and handling the payment prudently? Does the veteran handle
92 ;; the money and pay the bills himself or herself?
93 ;;
94 ;; Based on your examination, do you believe that the veteran is
95 ;; capable of managing his or her financial affairs?
96 ;; Please provide examples to support your conclusion.
97 ;;
98 ;; If you believe a Social Work Service assessment is needed before
99 ;; you can give your opinion on the veteran's ability to manage his
100 ;; or her financial affairs, please explain why.
101 ;;
102 ;; b. OTHER OPINION: Furnish any other specific opinion requested
103 ;; by the rating board or BVA Remand furnishing the complete
104 ;; rationale and citation of medical texts or treatise supporting
105 ;; opinion, if medical literature review was undertaken.
106 ;; If the requested opinion is medically not ascertainable on exam
107 ;; or testing, please indicate WHY. If the requested opinion can not
108 ;; be expressed without resorting to speculation or making improbable
109 ;; assumptions say so, and explain why. If the opinion asks "...is it
110 ;; at least as likely as not..?", fully explain the clinical findings
111 ;; and rationale for the opinion.
112 ;; 4. Include results of all diagnostic and clinical tests conducted
113 ;; in the examination report.
114 ;;
115 ;;E. Diagnosis:
116 ;; Provide:
117 ;;
118 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
119 ;; on the examination report.
120 ;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
121 ;; represents a progression of the prior diagnosis or development of a new
122 ;; and separate condition.
123 ;; 3. If there are multiple mental disorders, delineate to the extent possible
124 ;; the symptoms associated with each and a discussion of relationship.
125 ;; 4. Evaluation is based on the effects of the signs and symptoms on
126 ;; occupational and social functioning.
127 ;;
128 ;;NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
129 ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
130 ;;However, when a veteran's alcohol or drug abuse disability is secondary to
131 ;;or is caused or aggravated by a primary service-connected disorder, the
132 ;;veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
133 ;;1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
134 ;;relationship, if any, between a service-connected disorder and a disability
135 ;;resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
136 ;;abuse is secondary to or is caused or aggravated by another mental disorder,
137 ;;you should separate, to the extent possible, the effects of the alcohol or
138 ;;drug abuse from the effects of the other mental disorder(s). If it is not
139 ;;possible to separate the effects in such cases, please explain why.
140 ;;
141 ;;F. Global Assessment of Functioning (GAF):
142 ;;
143 ;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
144 ;;by BVA REMAND or specifically requested by the rating specialist. If so,
145 ;;include the GAF score and note whether it refers to current functioning.
146 ;;A BVA REMAND may also request, in addition to an overall GAF score, that a
147 ;;separate GAF score be provided for each mental disorder present when there are
148 ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
149 ;;If separate GAF scores can be given, an explanation and discussion of
150 ;;the rationale is needed. If it is not possible, an explanation as to why not is
151 ;;needed. (See the above note pertaining to alcohol or drug abuse.)
152 ;;
153 ;;
154 ;;Signature: Date:
155 ;;END
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