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Routine: DVBCWMD1

DVBCWMD1.m

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DVBCWMD1 ;ALB/CMM MENTAL DISORDERS WKS TEXT - 1 ; 5 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical history (subjective complaints):

 ;;

 ;;    Comment on:

 ;;    1.  PAST MEDICAL HISTORY:

 ;;

 ;;        a.  Previous hospitalizations and outpatient care.

 ;;

 ;;

 ;;        b.  Medical and occupational history from the time between 

 ;;            last rating examination and the present, UNLESS the 

 ;;            purpose of this examination is to ESTABLISH service 

 ;;            connection, then the complete medical history since 

 ;;            discharge from military service is required.

 ;;

 ;;

 ;;    2.  PRESENT MEDICAL, OCCUPATIONAL, AND SOCIAL HISTORY - over the 

 ;;        past one year.

 ;;

 ;;        a.  Frequency, severity, and duration of psychiatric symptoms.

 ;;

 ;;        b.  Length of remissions, to include capacity for adjustment 

 ;;            during periods of remissions.

 ;; 

 ;;        c.  Extent of time lost from work over the past 12 month 

 ;;            period and social impairment.  If employed, identify 

 ;;            current occupation and length of time at this job.  If 

 ;;            unemployed, note in complaints whether veteran contends it

 ;;            is due to the effects of a mental disorder.  Further 

 ;;            indicate following DIAGNOSIS what factors, and objective 

 ;;            findings support or rebut that contention.

 ;;

 ;;        d.  Treatments including statement on effectiveness and side 

 ;;            effects experienced.

 ;; 

 ;;    3.  SUBJECTIVE COMPLAINTS:

 ;;

 ;;        a.  Describe fully.

 ;;

 ;;TOF

 ;;C.  Examination (Objective Findings):

 ;;

 ;;    Address each of the following and fully describe:

 ;;    1.  Mental status exam to confirm or establish diagnosis in 

 ;;        accordance with DSM-IV.

 ;;

 ;;    2.  Additionally, to allow evaluation by the rating specialist, 

 ;;        describe and fully explain the existence, frequency, and 

 ;;        extent of the following signs and symptoms, or any others 

 ;;        present, and relate how they interfere with employment and 

 ;;        social functioning:

 ;; 

 ;;        a.  Impairment of thought process or communication.

 ;; 

 ;;

 ;;        b.  Delusions, hallucinations and their persistence.

 ;; 

 ;; 

 ;;        c.  Inappropriate behavior cited with examples.

 ;; 

 ;;

 ;;        d.  Suicidal or homicidal thoughts, ideations or plans or intent.

 ;;

 ;;

 ;;        e.  Ability to maintain personal hygiene and other basic 

 ;;            activities of daily living.

 ;; 

 ;;        f.  Orientation to person, place, and time.

 ;;

 ;;

 ;;        g.  Memory loss or impairment (both short and/or long term).

 ;; 

 ;; 

 ;;        h.  Obsessive or ritualistic behavior which interferes with 

 ;;            routine activities (describe with examples).

 ;; 

 ;; 

 ;;        i.  Rate and flow of speech and note irrelevant, illogical, or

 ;;            obscure speech patterns and whether constant or intermittent.

 ;; 

 ;; 

 ;;        j.  Panic attacks noting the severity, duration, frequency and

 ;;            effect on independent functioning and whether clinically

 ;;            observed or good evidence of prior clinical or equivalent

 ;;            observation.

 ;; 

 ;;        k.  Depression, depressed mood, or anxiety.

 ;;

 ;;        l.  Impaired impulse control and its effect on motivation or mood.

 ;;

 ;;

 ;;        m.  Sleep impairment and describe extent it interferes with 

 ;;            daytime activities.

 ;;

 ;;

 ;;        n.  Other symptoms and the extent to which they interfere with

 ;;            activities.

 ;;

 ;;

 ;;D.  Diagnostic Tests:

 ;;

 ;;    1.  Provide psychological testing if deemed necessary.

 ;;    2.  If testing is requested, the results must be reported and 

 ;;        considered in arriving at the diagnosis.

 ;;    3.  Provide any specific evaluation information required by the 

 ;;        rating board or on BVA Remand (in claims folder).

 ;;

 ;;        a.  COMPETENCY:  State whether the veteran is capable of 

 ;;            managing his/her benefit payments in the individual's own

 ;;            best interests (a physical disability which prevents the 

 ;;            veteran from attending to financial matters in person is 

 ;;            not a proper basis for a finding of incompetency unless 

 ;;            the veteran is, by reason of that disability, incapable of

 ;;            directing someone else in handling the individual's 

 ;;            financial affairs).

 ;;

 ;;        b.  OTHER OPINION:  Furnish any other specific opinion requested 

 ;;            by the rating board or BVA Remand furnishing the complete

 ;;            rationale and citation of medical texts or treatise 

 ;;            supporting opinion, if medical literature review was under-

 ;;            taken. If the requested opinion is medically not ascertainable 

 ;;            on exam or testing, please indicate why.  If the requested

 ;;            opinion can not be expressed without resorting to 

 ;;            speculation or making improbable assumptions say so, and 

 ;;            explain why.  If the opinion asks "...is it at least as 

 ;;            likely as not..?", fully explain the clinical findings and

 ;;            rationale for the opinion.

 ;;

 ;;    4.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;TOF

 ;;E.  Diagnosis: 

 ;;

 ;;    Provide:

 ;;    1.  The Diagnosis must conform to DSM-IV and be supported by the 

 ;;        findings on the examination report.

 ;;    2.  If the diagnosis is changed, explain fully whether the new 

 ;;        diagnosis represents a progression of the prior diagnosis or 

 ;;        development of a new and separate condition.

 ;;    3.  If there are multiple psychiatric conditions, delineate to the

 ;;        extent possible the symptoms associated with each and a 

 ;;        discussion of relationship.

 ;;    4.  Evaluation is based on the effects of the signs and symptoms 

 ;;        on occupational and social functioning.

 ;;

 ;;NOTE:  VA is prohibited by statute from paying compensation for a 

 ;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, 

 ;;whether based on direct service connection, secondary service connection, 

 ;;or aggravation by a service-connected condition.  Therefore, when 

 ;;alcohol or drug abuse accompanies or is associated with another mental

 ;;disorder, separate, to the extent possible, the effects of the alcohol

 ;;or drug abuse from the effects of the other mental disorder(s).  If it

 ;;is not possible to separate the effects, explain why.

 ;;

 ;;

 ;;

 ;;F.  Global Assessment of Functioning (GAF):

 ;;

 ;;NOTE:  The complete multi-axial format as specified by DSM-IV may 

 ;;be required by BVA REMAND or specifically requested by the rating 

 ;;specialist.  If so, include the GAF score and note whether it 

 ;;refers to current functioning over the past year, etc.

 ;;

 ;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent 

 ;;possible, to provide a GAF score for the service connected conditions

 ;;alone as well as a separate overall GAF score based on all mental 

 ;;disorders present and explain and discuss the rationale.  (See the 

 ;;above note pertaining to alcohol or drug abuse, effects of which cannot 

 ;;be used to assess the effects of a service-connected condition.)  If 

 ;;unable to separate symptomatology, explain why.

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END