DVBCTBI6 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
;;2.7;AMIE;**134**;Apr 10, 1995;Build 1
;
;
TXT ;
;; 11. Endocrine dysfunction. If evidence of endocrine dysfunction is
;; identified or suspected, select and follow the additional appropriate
;; examination protocol for the type of endocrine disorder identified.
;; 12. Autonomic dysfunction. Report any symptoms of autonomic dysfunction,
;; such as heat intolerance, excess or decreased sweating, etc.
;; 13. Other abnormal physical findings.
;; 14. Assessment of cognitive impairment and other residuals of TBI not
;; otherwise classified:
;;
;;Instruction: Answer the following specific questions about each of the
;;following items (after completion of neuropsychological testing, if done).
;;State on the examination report which of the choices best describes each of
;;the items. Do not report by using the number of the item or the letter of
;;the description. Report the title of the item: "Memory, attention,
;;concentration, executive functions," etc., and then state the correct
;;description, e.g., "There is objective evidence on testing of mild impairment
;;of memory (and/or attention, and/or concentration, and/or executive functions)
;;resulting in mild functional impairment."
;;
;; I. Memory, attention, concentration, executive functions
;; a. No complaints of impairment of memory, attention, concentration or
;; executive functions.
;; b. A complaint of mild memory loss (such as having difficulty following
;; a conversation, recalling recent conversations, remembering names of new
;; acquaintances, or finding words, or often misplacing items), attention,
;; concentration, or executive functions, but without objective evidence
;; on testing.
;; c. Objective evidence on testing of mild impairment of memory,
;; attention, concentration, or executive functions resulting in mild
;; functional impairment.
;; d. Objective evidence on testing of moderate impairment of memory,
;; attention, concentration, or executive functions resulting in moderate
;; functional impairment.
;; e. Objective evidence on testing of severe impairment of memory,
;; attention, concentration, or executive functions resulting in severe
;; functional impairment.
;;
;; II. Judgment
;; a. Normal.
;; b. Mildly impaired judgment. For complex or unfamiliar decisions,
;; occasionally unable to identify, understand, and weigh the alternatives,
;; understand the consequences of choices, and make a reasonable decision.
;; c. Moderately impaired judgment. For complex or unfamiliar decisions,
;; usually unable to identify, understand, and weigh the alternatives,
;; understand the consequences of choices, and make a reasonable decision,
;; although has little difficulty with simple decisions.
;; d. Moderately severely impaired judgment. For even routine and familiar
;; decisions, occasionally unable to identify, understand, and weigh the
;; alternatives, understand the consequences of choices, and make a
;; reasonable decision.
;; e. Severely impaired judgment. For even routine and familiar decisions,
;; usually unable to identify, understand, and weigh the alternatives,
;; understand the consequences of choices, and make a reasonable decision.
;; For example, unable to determine appropriate clothing for current
;; weather conditions or judge when to avoid dangerous situations or
;; activities.
;;
;; III. Social Interaction
;; a. Social interaction is routinely appropriate.
;; b. Social interaction is occasionally inappropriate.
;; c. Social interaction is frequently inappropriate.
;; d. Social interaction is inappropriate most or all of the time.
;;
;; IV. Orientation
;; a. Always oriented to person, time, place, and situation.
;; b. Occasionally disoriented to one of the four aspects (person, time,
;; place, situation) of orientation.
;; c. Occasionally disoriented to two of the four aspects (person, time,
;; place, situation) of orientation or often disoriented to one aspect of
;; orientation.
;; d. Often disoriented to two or more of the four aspects (person, time,
;; place, situation) of orientation.
;; e. Consistently disoriented to two or more of the four aspects (person,
;; time, place, situation) of orientation.
;;
;; V. Motor activity (with intact motor and sensory system)
;; a. Motor activity normal.
;; b. Motor activity normal most of the time, but mildly slowed at times
;; due to apraxia (inability to perform previously learned motor activities,
;; despite normal motor function).
;; c. Motor activity mildly decreased or with moderate slowing due to
;; apraxia.
;; d. Motor activity moderately decreased due to apraxia.
;; e. Motor activity severely decreased due to apraxia.
;;
;; VI. Visual spatial orientation
;; a. Normal.
;; b. Mildly impaired. Occasionally gets lost in unfamiliar surroundings,
;; has difficulty reading maps or following directions. Is able to use
;; assistive devices such as GPS (global positioning system).
;; c. Moderately impaired. Usually gets lost in unfamiliar surroundings,
;; has difficulty reading maps, following directions, and judging distance.
;; Has difficulty using assistive devices such as GPS (global positioning
;; system).
;; d. Moderately severely impaired. Gets lost even in familiar
;; surroundings, unable to use assistive devices such as GPS (global
;; positioning system).
;; e. Severely impaired. May be unable to touch or name own body parts
;; when asked by the examiner, identify the relative position in space of
;; two different objects, or find the way from one room to another in a
;; familiar environment.
;;
;; VII. Subjective symptoms
;; a. Subjective symptoms that do not interfere with work; instrumental
;; activities of daily living; or work, family, or other close
;; relationships. Examples are: mild or occasional headaches, mild
;; anxiety.
;; b. Three or more subjective symptoms that mildly interfere with work;
;; instrumental activities of daily living; or work, family, or other
;; close relationships. Examples of findings that might be seen at this
;; level of impairment are: intermittent dizziness, daily mild to moderate
;; headaches, tinnitus, frequent insomnia, hypersensitivity to sound,
;; hypersensitivity to light.
;; c. Three or more subjective symptoms that moderately interfere with
;; work; instrumental activities of daily living; or work, family, or other
;; close relationships. Examples of findings that might be seen at this
;; level of impairment are: marked fatigability, blurred or double vision,
;; headaches requiring rest periods during most days.
;;
;;VIII. Neurobehavioral effects
;; a. One or more neurobehavioral effects that do not interfere with
;; workplace interaction or social interaction. Examples of
;; neurobehavioral effects are: irritability, impulsivity,
;; unpredictability, lack of motivation, verbal aggression, physical
;; aggression, belligerence, apathy, lack of empathy, moodiness, lack of
;; cooperation, inflexibility, and impaired awareness of disability. Any
;; of these effects may range from slight to severe, although verbal and
;; physical aggression are likely to have a more serious impact on
;; workplace interaction and social interaction than some of the other
;; effects.
;; b. One or more neurobehavioral effects that occasionally interfere with
;; workplace interaction, social interaction, or both but do not preclude
;; them.
;; c. One or more neurobehavioral effects that frequently interfere with
;; workplace interaction, social interaction, or both but do not preclude
;; them.
;; d. One or more neurobehavioral effects that interfere with or preclude
;; workplace interaction, social interaction, or both on most days or that
;; occasionally require supervision for safety of self or others.
;;
;; IX. Communication
;; a. Able to communicate by spoken and written language (expressive
;; communication), and to comprehend spoken and written language.
;; b. Comprehension or expression, or both, of either spoken language or
;; written language is only occasionally impaired. Can communicate complex
;; ideas.
;; c. Inability to communicate either by spoken language, written language,
;; or both, more than occasionally but less than half of the time, or to
;; comprehend spoken language, written language, or both, more than
;; occasionally but less than half of the time. Can generally communicate
;; complex ideas.
;; d. Inability to communicate either by spoken language, written language,
;; or both, at least half of the time but not all of the time, or to
;; comprehend spoken language, written language, or both, at least half of
;; the time but not all of the time. May rely on gestures or other
;; alternative modes of communication. Able to communicate basic needs.
;; e. Complete inability to communicate either by spoken language, written
;; language, or both, or to comprehend spoken language, written language,
;; or both. Unable to communicate basic needs.
;;
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCTBI6 9967 printed Nov 22, 2024@16:59:06 Page 2
DVBCTBI6 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
+1 ;;2.7;AMIE;**134**;Apr 10, 1995;Build 1
+2 ;
+3 ;
TXT ;
+1 ;; 11. Endocrine dysfunction. If evidence of endocrine dysfunction is
+2 ;; identified or suspected, select and follow the additional appropriate
+3 ;; examination protocol for the type of endocrine disorder identified.
+4 ;; 12. Autonomic dysfunction. Report any symptoms of autonomic dysfunction,
+5 ;; such as heat intolerance, excess or decreased sweating, etc.
+6 ;; 13. Other abnormal physical findings.
+7 ;; 14. Assessment of cognitive impairment and other residuals of TBI not
+8 ;; otherwise classified:
+9 ;;
+10 ;;Instruction: Answer the following specific questions about each of the
+11 ;;following items (after completion of neuropsychological testing, if done).
+12 ;;State on the examination report which of the choices best describes each of
+13 ;;the items. Do not report by using the number of the item or the letter of
+14 ;;the description. Report the title of the item: "Memory, attention,
+15 ;;concentration, executive functions," etc., and then state the correct
+16 ;;description, e.g., "There is objective evidence on testing of mild impairment
+17 ;;of memory (and/or attention, and/or concentration, and/or executive functions)
+18 ;;resulting in mild functional impairment."
+19 ;;
+20 ;; I. Memory, attention, concentration, executive functions
+21 ;; a. No complaints of impairment of memory, attention, concentration or
+22 ;; executive functions.
+23 ;; b. A complaint of mild memory loss (such as having difficulty following
+24 ;; a conversation, recalling recent conversations, remembering names of new
+25 ;; acquaintances, or finding words, or often misplacing items), attention,
+26 ;; concentration, or executive functions, but without objective evidence
+27 ;; on testing.
+28 ;; c. Objective evidence on testing of mild impairment of memory,
+29 ;; attention, concentration, or executive functions resulting in mild
+30 ;; functional impairment.
+31 ;; d. Objective evidence on testing of moderate impairment of memory,
+32 ;; attention, concentration, or executive functions resulting in moderate
+33 ;; functional impairment.
+34 ;; e. Objective evidence on testing of severe impairment of memory,
+35 ;; attention, concentration, or executive functions resulting in severe
+36 ;; functional impairment.
+37 ;;
+38 ;; II. Judgment
+39 ;; a. Normal.
+40 ;; b. Mildly impaired judgment. For complex or unfamiliar decisions,
+41 ;; occasionally unable to identify, understand, and weigh the alternatives,
+42 ;; understand the consequences of choices, and make a reasonable decision.
+43 ;; c. Moderately impaired judgment. For complex or unfamiliar decisions,
+44 ;; usually unable to identify, understand, and weigh the alternatives,
+45 ;; understand the consequences of choices, and make a reasonable decision,
+46 ;; although has little difficulty with simple decisions.
+47 ;; d. Moderately severely impaired judgment. For even routine and familiar
+48 ;; decisions, occasionally unable to identify, understand, and weigh the
+49 ;; alternatives, understand the consequences of choices, and make a
+50 ;; reasonable decision.
+51 ;; e. Severely impaired judgment. For even routine and familiar decisions,
+52 ;; usually unable to identify, understand, and weigh the alternatives,
+53 ;; understand the consequences of choices, and make a reasonable decision.
+54 ;; For example, unable to determine appropriate clothing for current
+55 ;; weather conditions or judge when to avoid dangerous situations or
+56 ;; activities.
+57 ;;
+58 ;; III. Social Interaction
+59 ;; a. Social interaction is routinely appropriate.
+60 ;; b. Social interaction is occasionally inappropriate.
+61 ;; c. Social interaction is frequently inappropriate.
+62 ;; d. Social interaction is inappropriate most or all of the time.
+63 ;;
+64 ;; IV. Orientation
+65 ;; a. Always oriented to person, time, place, and situation.
+66 ;; b. Occasionally disoriented to one of the four aspects (person, time,
+67 ;; place, situation) of orientation.
+68 ;; c. Occasionally disoriented to two of the four aspects (person, time,
+69 ;; place, situation) of orientation or often disoriented to one aspect of
+70 ;; orientation.
+71 ;; d. Often disoriented to two or more of the four aspects (person, time,
+72 ;; place, situation) of orientation.
+73 ;; e. Consistently disoriented to two or more of the four aspects (person,
+74 ;; time, place, situation) of orientation.
+75 ;;
+76 ;; V. Motor activity (with intact motor and sensory system)
+77 ;; a. Motor activity normal.
+78 ;; b. Motor activity normal most of the time, but mildly slowed at times
+79 ;; due to apraxia (inability to perform previously learned motor activities,
+80 ;; despite normal motor function).
+81 ;; c. Motor activity mildly decreased or with moderate slowing due to
+82 ;; apraxia.
+83 ;; d. Motor activity moderately decreased due to apraxia.
+84 ;; e. Motor activity severely decreased due to apraxia.
+85 ;;
+86 ;; VI. Visual spatial orientation
+87 ;; a. Normal.
+88 ;; b. Mildly impaired. Occasionally gets lost in unfamiliar surroundings,
+89 ;; has difficulty reading maps or following directions. Is able to use
+90 ;; assistive devices such as GPS (global positioning system).
+91 ;; c. Moderately impaired. Usually gets lost in unfamiliar surroundings,
+92 ;; has difficulty reading maps, following directions, and judging distance.
+93 ;; Has difficulty using assistive devices such as GPS (global positioning
+94 ;; system).
+95 ;; d. Moderately severely impaired. Gets lost even in familiar
+96 ;; surroundings, unable to use assistive devices such as GPS (global
+97 ;; positioning system).
+98 ;; e. Severely impaired. May be unable to touch or name own body parts
+99 ;; when asked by the examiner, identify the relative position in space of
+100 ;; two different objects, or find the way from one room to another in a
+101 ;; familiar environment.
+102 ;;
+103 ;; VII. Subjective symptoms
+104 ;; a. Subjective symptoms that do not interfere with work; instrumental
+105 ;; activities of daily living; or work, family, or other close
+106 ;; relationships. Examples are: mild or occasional headaches, mild
+107 ;; anxiety.
+108 ;; b. Three or more subjective symptoms that mildly interfere with work;
+109 ;; instrumental activities of daily living; or work, family, or other
+110 ;; close relationships. Examples of findings that might be seen at this
+111 ;; level of impairment are: intermittent dizziness, daily mild to moderate
+112 ;; headaches, tinnitus, frequent insomnia, hypersensitivity to sound,
+113 ;; hypersensitivity to light.
+114 ;; c. Three or more subjective symptoms that moderately interfere with
+115 ;; work; instrumental activities of daily living; or work, family, or other
+116 ;; close relationships. Examples of findings that might be seen at this
+117 ;; level of impairment are: marked fatigability, blurred or double vision,
+118 ;; headaches requiring rest periods during most days.
+119 ;;
+120 ;;VIII. Neurobehavioral effects
+121 ;; a. One or more neurobehavioral effects that do not interfere with
+122 ;; workplace interaction or social interaction. Examples of
+123 ;; neurobehavioral effects are: irritability, impulsivity,
+124 ;; unpredictability, lack of motivation, verbal aggression, physical
+125 ;; aggression, belligerence, apathy, lack of empathy, moodiness, lack of
+126 ;; cooperation, inflexibility, and impaired awareness of disability. Any
+127 ;; of these effects may range from slight to severe, although verbal and
+128 ;; physical aggression are likely to have a more serious impact on
+129 ;; workplace interaction and social interaction than some of the other
+130 ;; effects.
+131 ;; b. One or more neurobehavioral effects that occasionally interfere with
+132 ;; workplace interaction, social interaction, or both but do not preclude
+133 ;; them.
+134 ;; c. One or more neurobehavioral effects that frequently interfere with
+135 ;; workplace interaction, social interaction, or both but do not preclude
+136 ;; them.
+137 ;; d. One or more neurobehavioral effects that interfere with or preclude
+138 ;; workplace interaction, social interaction, or both on most days or that
+139 ;; occasionally require supervision for safety of self or others.
+140 ;;
+141 ;; IX. Communication
+142 ;; a. Able to communicate by spoken and written language (expressive
+143 ;; communication), and to comprehend spoken and written language.
+144 ;; b. Comprehension or expression, or both, of either spoken language or
+145 ;; written language is only occasionally impaired. Can communicate complex
+146 ;; ideas.
+147 ;; c. Inability to communicate either by spoken language, written language,
+148 ;; or both, more than occasionally but less than half of the time, or to
+149 ;; comprehend spoken language, written language, or both, more than
+150 ;; occasionally but less than half of the time. Can generally communicate
+151 ;; complex ideas.
+152 ;; d. Inability to communicate either by spoken language, written language,
+153 ;; or both, at least half of the time but not all of the time, or to
+154 ;; comprehend spoken language, written language, or both, at least half of
+155 ;; the time but not all of the time. May rely on gestures or other
+156 ;; alternative modes of communication. Able to communicate basic needs.
+157 ;; e. Complete inability to communicate either by spoken language, written
+158 ;; language, or both, or to comprehend spoken language, written language,
+159 ;; or both. Unable to communicate basic needs.
+160 ;;
