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1DVBCWMO1 ;ALB/JFP MENTAL DISORDERS (EXCEPT INITIAL PTSD AND EATING DISORDERS) WKS TEXT - 1 ; 13 FEB 1998
2 ;;2.7;AMIE;**16**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;; 1. Past Medical History:
12 ;;
13 ;; a. Previous hospitalizations and outpatient care.
14 ;;
15 ;; b. Medical and occupational history from the time between
16 ;; last rating examination and the present, UNLESS the
17 ;; purpose of this examination is to ESTABLISH service
18 ;; connection, then the complete medical history since
19 ;; discharge from military service is required.
20 ;;
21 ;; 2. Present Medical, Occupational, and Social History - over the
22 ;; past one year.
23 ;;
24 ;; a. Frequency, severity, and duration of psychiatric symptoms.
25 ;;
26 ;; b. Length of remissions, to include capacity for adjustment
27 ;; during periods of remissions.
28 ;;
29 ;; c. Extent of time lost from work over the past 12 month
30 ;; period and social impairment. If employed, identify
31 ;; current occupation and length of time at this job. If
32 ;; unemployed, note in complaints whether veteran contends it
33 ;; is due to the effects of a mental disorder. Further
34 ;; indicate following DIAGNOSIS what factors, and objective
35 ;; findings support or rebut that contention.
36 ;;
37 ;; d. Treatments including statement on effectiveness and side
38 ;; effects experienced.
39 ;;
40 ;; 3. Subjective Complaints:
41 ;;
42 ;; a. Describe fully.
43 ;;
44 ;;TOF
45 ;;C. Examination (Objective Findings):
46 ;;
47 ;; Address each of the following and fully describe:
48 ;; 1. Mental status exam to confirm or establish diagnosis in
49 ;; accordance with DSM-IV.
50 ;;
51 ;; 2. Additionally, to allow evaluation by the rating specialist,
52 ;; describe and fully explain the existence, frequency, and
53 ;; extent of the following signs and symptoms, or any others
54 ;; present, and relate how they interfere with employment and
55 ;; social functioning:
56 ;;
57 ;; a. Impairment of thought process or communication.
58 ;;
59 ;; b. Delusions, hallucinations and their persistence.
60 ;;
61 ;; c. Inappropriate behavior cited with examples.
62 ;;
63 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
64 ;;
65 ;; e. Ability to maintain personal hygiene and other basic
66 ;; activities of daily living.
67 ;;
68 ;; f. Orientation to person, place, and time.
69 ;;
70 ;; g. Memory loss or impairment (both short and/or long term).
71 ;;
72 ;; h. Obsessive or ritualistic behavior which interferes with
73 ;; routine activities (describe with examples).
74 ;;
75 ;; i. Rate and flow of speech and note irrelevant, illogical, or
76 ;; obscure speech patterns and whether constant or intermittent.
77 ;;
78 ;; j. Panic attacks noting the severity, duration, frequency and
79 ;; effect on independent functioning and whether clinically
80 ;; observed or good evidence of prior clinical or equivalent
81 ;; observation.
82 ;;
83 ;; k. Depression, depressed mood, or anxiety.
84 ;;
85 ;; l. Impaired impulse control and its effect on motivation or mood.
86 ;;
87 ;; m. Sleep impairment and describe extent it interferes with
88 ;; daytime activities.
89 ;;
90 ;; n. Other symptoms and the extent to which they interfere with
91 ;; activities.
92 ;;
93 ;;TOF
94 ;;D. Diagnostic Tests:
95 ;;
96 ;; 1. Provide psychological testing if deemed necessary.
97 ;; 2. If testing is requested, the results must be reported and
98 ;; considered in arriving at the diagnosis.
99 ;; 3. Provide any specific evaluation information required by the
100 ;; rating board or on BVA Remand (in claims folder).
101 ;;
102 ;; a. COMPETENCY: State whether the veteran is capable of
103 ;; managing his/her benefit payments in the individual's own
104 ;; best interests (a physical disability which prevents the
105 ;; veteran from attending to financial matters in person is
106 ;; not a proper basis for a finding of incompetency unless
107 ;; the veteran is, by reason of that disability, incapable of
108 ;; directing someone else in handling the individual's
109 ;; financial affairs).
110 ;;
111 ;; b. OTHER OPINION: Furnish any other specific opinion requested
112 ;; by the rating board or BVA Remand furnishing the complete
113 ;; rationale and citation of medical texts or treatise
114 ;; supporting opinion, if medical literature review was under-
115 ;; taken. If the requested opinion is medically not ascertainable
116 ;; on exam or testing, please indicate why. If the requested
117 ;; opinion can not be expressed without resorting to
118 ;; speculation or making improbable assumptions say so, and
119 ;; explain why. If the opinion asks "...is it at least as
120 ;; likely as not..?", fully explain the clinical findings and
121 ;; rationale for the opinion.
122 ;;
123 ;; 4. Include results of all diagnostic and clinical tests conducted
124 ;; in the examination report.
125 ;;
126 ;;TOF
127 ;;E. Diagnosis:
128 ;;
129 ;; Provide:
130 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the
131 ;; findings on the examination report.
132 ;; 2. If the diagnosis is changed, explain fully whether the new
133 ;; diagnosis represents a progression of the prior diagnosis or
134 ;; development of a new and separate condition.
135 ;; 3. If there are multiple mental disorders, delineate to the
136 ;; extent possible the symptoms associated with each and a
137 ;; discussion of relationship.
138 ;; 4. Evaluation is based on the effects of the signs and symptoms
139 ;; on occupational and social functioning.
140 ;;
141 ;;NOTE: VA is prohibited by statute from paying compensation for a
142 ;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE,
143 ;;whether based on direct service connection, secondary service connection,
144 ;;or aggravation by a service-connected condition. Therefore, when
145 ;;alcohol or drug abuse accompanies or is associated with another mental
146 ;;disorder, separate, to the extent possible, the effects of the alcohol
147 ;;or drug abuse from the effects of the other mental disorder(s). If it
148 ;;is not possible to separate the effects, explain why.
149 ;;
150 ;;
151 ;;F. Global Assessment of Functioning (GAF):
152 ;;
153 ;;NOTE: The complete multi-axial format as specified by DSM-IV may
154 ;;be required by BVA REMAND or specifically requested by the rating
155 ;;specialist. If so, include the GAF score and note whether it
156 ;;refers to current functioning over the past year, etc.
157 ;;
158 ;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent
159 ;;possible, to provide a GAF score for the service connected conditions
160 ;;alone as well as a separate overall GAF score based on all mental
161 ;;disorders present and explain and discuss the rationale. (See the
162 ;;above note pertaining to alcohol or drug abuse, effects of which cannot
163 ;;be used to assess the effects of a service-connected condition.) If
164 ;;unable to separate symptomatology, explain why.
165 ;;
166 ;;
167 ;;Signature: Date:
168 ;;END
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