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Routine: DVBCWMD1

DVBCWMD1.m

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  1. DVBCWMD1 ;ALB/CMM MENTAL DISORDERS WKS TEXT - 1 ; 5 MARCH 1997
  1.  ;;2.7;AMIE;**12**;Apr 10, 1995
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;B.  Medical history (subjective complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;    1.  PAST MEDICAL HISTORY:
  1.  ;;
  1.  ;;        a.  Previous hospitalizations and outpatient care.
  1.  ;;
  1.  ;;
  1.  ;;        b.  Medical and occupational history from the time between 
  1.  ;;            last rating examination and the present, UNLESS the 
  1.  ;;            purpose of this examination is to ESTABLISH service 
  1.  ;;            connection, then the complete medical history since 
  1.  ;;            discharge from military service is required.
  1.  ;;
  1.  ;;
  1.  ;;    2.  PRESENT MEDICAL, OCCUPATIONAL, AND SOCIAL HISTORY - over the 
  1.  ;;        past one year.
  1.  ;;
  1.  ;;        a.  Frequency, severity, and duration of psychiatric symptoms.
  1.  ;;
  1.  ;;        b.  Length of remissions, to include capacity for adjustment 
  1.  ;;            during periods of remissions.
  1.  ;; 
  1.  ;;        c.  Extent of time lost from work over the past 12 month 
  1.  ;;            period and social impairment.  If employed, identify 
  1.  ;;            current occupation and length of time at this job.  If 
  1.  ;;            unemployed, note in complaints whether veteran contends it
  1.  ;;            is due to the effects of a mental disorder.  Further 
  1.  ;;            indicate following DIAGNOSIS what factors, and objective 
  1.  ;;            findings support or rebut that contention.
  1.  ;;
  1.  ;;        d.  Treatments including statement on effectiveness and side 
  1.  ;;            effects experienced.
  1.  ;; 
  1.  ;;    3.  SUBJECTIVE COMPLAINTS:
  1.  ;;
  1.  ;;        a.  Describe fully.
  1.  ;;
  1.  ;;TOF
  1.  ;;C.  Examination (Objective Findings):
  1.  ;;
  1.  ;;    Address each of the following and fully describe:
  1.  ;;    1.  Mental status exam to confirm or establish diagnosis in 
  1.  ;;        accordance with DSM-IV.
  1.  ;;
  1.  ;;    2.  Additionally, to allow evaluation by the rating specialist, 
  1.  ;;        describe and fully explain the existence, frequency, and 
  1.  ;;        extent of the following signs and symptoms, or any others 
  1.  ;;        present, and relate how they interfere with employment and 
  1.  ;;        social functioning:
  1.  ;; 
  1.  ;;        a.  Impairment of thought process or communication.
  1.  ;; 
  1.  ;;
  1.  ;;        b.  Delusions, hallucinations and their persistence.
  1.  ;; 
  1.  ;; 
  1.  ;;        c.  Inappropriate behavior cited with examples.
  1.  ;; 
  1.  ;;
  1.  ;;        d.  Suicidal or homicidal thoughts, ideations or plans or intent.
  1.  ;;
  1.  ;;
  1.  ;;        e.  Ability to maintain personal hygiene and other basic 
  1.  ;;            activities of daily living.
  1.  ;; 
  1.  ;;        f.  Orientation to person, place, and time.
  1.  ;;
  1.  ;;
  1.  ;;        g.  Memory loss or impairment (both short and/or long term).
  1.  ;; 
  1.  ;; 
  1.  ;;        h.  Obsessive or ritualistic behavior which interferes with 
  1.  ;;            routine activities (describe with examples).
  1.  ;; 
  1.  ;; 
  1.  ;;        i.  Rate and flow of speech and note irrelevant, illogical, or
  1.  ;;            obscure speech patterns and whether constant or intermittent.
  1.  ;; 
  1.  ;; 
  1.  ;;        j.  Panic attacks noting the severity, duration, frequency and
  1.  ;;            effect on independent functioning and whether clinically
  1.  ;;            observed or good evidence of prior clinical or equivalent
  1.  ;;            observation.
  1.  ;; 
  1.  ;;        k.  Depression, depressed mood, or anxiety.
  1.  ;;
  1.  ;;        l.  Impaired impulse control and its effect on motivation or mood.
  1.  ;;
  1.  ;;
  1.  ;;        m.  Sleep impairment and describe extent it interferes with 
  1.  ;;            daytime activities.
  1.  ;;
  1.  ;;
  1.  ;;        n.  Other symptoms and the extent to which they interfere with
  1.  ;;            activities.
  1.  ;;
  1.  ;;
  1.  ;;D.  Diagnostic Tests:
  1.  ;;
  1.  ;;    1.  Provide psychological testing if deemed necessary.
  1.  ;;    2.  If testing is requested, the results must be reported and 
  1.  ;;        considered in arriving at the diagnosis.
  1.  ;;    3.  Provide any specific evaluation information required by the 
  1.  ;;        rating board or on BVA Remand (in claims folder).
  1.  ;;
  1.  ;;        a.  COMPETENCY:  State whether the veteran is capable of 
  1.  ;;            managing his/her benefit payments in the individual's own
  1.  ;;            best interests (a physical disability which prevents the 
  1.  ;;            veteran from attending to financial matters in person is 
  1.  ;;            not a proper basis for a finding of incompetency unless 
  1.  ;;            the veteran is, by reason of that disability, incapable of
  1.  ;;            directing someone else in handling the individual's 
  1.  ;;            financial affairs).
  1.  ;;
  1.  ;;        b.  OTHER OPINION:  Furnish any other specific opinion requested 
  1.  ;;            by the rating board or BVA Remand furnishing the complete
  1.  ;;            rationale and citation of medical texts or treatise 
  1.  ;;            supporting opinion, if medical literature review was under-
  1.  ;;            taken. If the requested opinion is medically not ascertainable 
  1.  ;;            on exam or testing, please indicate why.  If the requested
  1.  ;;            opinion can not be expressed without resorting to 
  1.  ;;            speculation or making improbable assumptions say so, and 
  1.  ;;            explain why.  If the opinion asks "...is it at least as 
  1.  ;;            likely as not..?", fully explain the clinical findings and
  1.  ;;            rationale for the opinion.
  1.  ;;
  1.  ;;    4.  Include results of all diagnostic and clinical tests conducted
  1.  ;;        in the examination report.
  1.  ;;
  1.  ;;TOF
  1.  ;;E.  Diagnosis: 
  1.  ;;
  1.  ;;    Provide:
  1.  ;;    1.  The Diagnosis must conform to DSM-IV and be supported by the 
  1.  ;;        findings on the examination report.
  1.  ;;    2.  If the diagnosis is changed, explain fully whether the new 
  1.  ;;        diagnosis represents a progression of the prior diagnosis or 
  1.  ;;        development of a new and separate condition.
  1.  ;;    3.  If there are multiple psychiatric conditions, delineate to the
  1.  ;;        extent possible the symptoms associated with each and a 
  1.  ;;        discussion of relationship.
  1.  ;;    4.  Evaluation is based on the effects of the signs and symptoms 
  1.  ;;        on occupational and social functioning.
  1.  ;;
  1.  ;;NOTE:  VA is prohibited by statute from paying compensation for a 
  1.  ;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, 
  1.  ;;whether based on direct service connection, secondary service connection, 
  1.  ;;or aggravation by a service-connected condition.  Therefore, when 
  1.  ;;alcohol or drug abuse accompanies or is associated with another mental
  1.  ;;disorder, separate, to the extent possible, the effects of the alcohol
  1.  ;;or drug abuse from the effects of the other mental disorder(s).  If it
  1.  ;;is not possible to separate the effects, explain why.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;F.  Global Assessment of Functioning (GAF):
  1.  ;;
  1.  ;;NOTE:  The complete multi-axial format as specified by DSM-IV may 
  1.  ;;be required by BVA REMAND or specifically requested by the rating 
  1.  ;;specialist.  If so, include the GAF score and note whether it 
  1.  ;;refers to current functioning over the past year, etc.
  1.  ;;
  1.  ;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent 
  1.  ;;possible, to provide a GAF score for the service connected conditions
  1.  ;;alone as well as a separate overall GAF score based on all mental 
  1.  ;;disorders present and explain and discuss the rationale.  (See the 
  1.  ;;above note pertaining to alcohol or drug abuse, effects of which cannot 
  1.  ;;be used to assess the effects of a service-connected condition.)  If 
  1.  ;;unable to separate symptomatology, explain why.
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END