- DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
- ;;2.7;AMIE;**34**;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.
- ;;
- ;;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 minimal 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 undertaken.
- ;; 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 mental disorders, 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.
- ;;A BVA REMAND may also request , in addition to an overall GAF score, that a
- ;;separate GAF score be provided for each mental disorder present when there are
- ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
- ;;If separate GAF scores can be given, an explanation and discussion of
- ;;the rationale is needed. If it is not possible, an explanation as to why not is
- ;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
- ;; which cannot be used to assess the effects of a service-connected condition.)
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWME1 7523 printed Jan 18, 2025@02:53:46 Page 2
- DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
- +1 ;;2.7;AMIE;**34**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;B. Medical History (Subjective Complaints):
- +4 ;; Comment on:
- +5 ;;
- +6 ;; 1. Past Medical History:
- +7 ;;
- +8 ;; a. Previous hospitalizations and outpatient care.
- +9 ;; b. Medical and occupational history from the time between last rating
- +10 ;; examination and the present, UNLESS the purpose of this examination
- +11 ;; is to ESTABLISH service connection, then the complete medical history
- +12 ;; since discharge from military service is required.
- +13 ;;
- +14 ;; 2. Present Medical, Occupational, and Social History -
- +15 ;; over the past one year.
- +16 ;;
- +17 ;; a. Frequency, severity, and duration of psychiatric symptoms.
- +18 ;; b. Length of remissions, to include capacity for adjustment during
- +19 ;; periods of remissions.
- +20 ;; c. Extent of time lost from work over the past 12 month period and
- +21 ;; social impairment. If employed, identify current occupation and
- +22 ;; length of time at this job. If unemployed, note in Complaints whether
- +23 ;; veteran contends it is due to the effects of a mental disorder.
- +24 ;; Further indicate following DIAGNOSIS what factors, and objective
- +25 ;; findings support or rebut that contention.
- +26 ;; d. Treatments including statement on effectiveness and side effects
- +27 ;; experienced.
- +28 ;;
- +29 ;; 3. Subjective Complaints:
- +30 ;;
- +31 ;; a. Describe fully.
- +32 ;;
- +33 ;;C. Examination (Objective Findings):
- +34 ;; Address each of the following and fully describe:
- +35 ;;
- +36 ;; 1. Mental status exam to confirm or establish diagnosis in
- +37 ;; accordance with DSM-IV.
- +38 ;; 2. Additionally, to allow evaluation by the rating specialist, describe
- +39 ;; and fully explain the existence, frequency, and extent of the following
- +40 ;; signs and symptoms, or any others present, and relate how they interfere
- +41 ;; with employment and social functioning:
- +42 ;; a. Impairment of thought process or communication.
- +43 ;; b. Delusions, hallucinations and their persistence.
- +44 ;; c. Inappropriate behavior cited with examples.
- +45 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
- +46 ;; e. Ability to maintain minimal personal hygiene and other basic
- +47 ;; activities of daily living.
- +48 ;; f. Orientation to person, place and time.
- +49 ;; g. Memory loss or impairment (both short and/or long term).
- +50 ;; h. Obsessive or ritualistic behavior which interferes with routine
- +51 ;; activities (describe with examples).
- +52 ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
- +53 ;; speech patterns and whether constant or intermittent.
- +54 ;; j. Panic attacks noting the severity, duration, frequency and effect
- +55 ;; on independent functioning and whether clinically observed or good
- +56 ;; evidence of prior clinical or equivalent observation.
- +57 ;; k. Depression, depressed mood, or anxiety.
- +58 ;; l. Impaired impulse control and its effect on motivation or mood.
- +59 ;; m. Sleep impairment and describe extent it interferes with daytime
- +60 ;; activities.
- +61 ;; n. Other symptoms and the extent to which they interfere with
- +62 ;; activities.
- +63 ;;
- +64 ;;D. Diagnostic Tests:
- +65 ;; 1. Provide psychological testing if deemed necessary.
- +66 ;; 2. If testing is requested, the results must be reported and considered in
- +67 ;; arriving at the diagnosis.
- +68 ;; 3. Provide any specific evaluation information required by the rating board
- +69 ;; or on BVA Remand (in claims folder).
- +70 ;;
- +71 ;; a. COMPETENCY: State whether the veteran is capable of managing
- +72 ;; his/her benefit payments in the individual's own best interests
- +73 ;; (a physical disability which prevents the veteran from attending
- +74 ;; to financial matters in person is not a proper basis for a finding
- +75 ;; of incompetency unless the veteran is, by reason of that
- +76 ;; disability, incapable of directing someone else in handling
- +77 ;; the individual's financial affairs).
- +78 ;;
- +79 ;; b. OTHER OPINION: Furnish any other specific opinion requested
- +80 ;; by the rating board or BVA Remand furnishing the complete
- +81 ;; rationale and citation of medical texts or treatise supporting
- +82 ;; opinion, if medical literature review was undertaken.
- +83 ;; If the requested opinion is medically not ascertainable on exam
- +84 ;; or testing, please indicate WHY. If the requested opinion can not
- +85 ;; be expressed without resorting to speculation or making improbable
- +86 ;; assumptions say so, and explain why. If the opinion asks "...is it
- +87 ;; at least as likely as not..?", fully explain the clinical findings
- +88 ;; and rationale for the opinion.
- +89 ;; 4. Include results of all diagnostic and clinical tests conducted
- +90 ;; in the examination report.
- +91 ;;TOF
- +92 ;;E. Diagnosis:
- +93 ;; Provide:
- +94 ;;
- +95 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
- +96 ;; on the examination report.
- +97 ;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
- +98 ;; represents a progression of the prior diagnosis or development of a new
- +99 ;; and separate condition.
- +100 ;; 3. If there are multiple mental disorders, delineate to the extent possible
- +101 ;; the symptoms associated with each and a discussion of relationship.
- +102 ;; 4. Evaluation is based on the effects of the signs and symptoms on
- +103 ;; occupational and social functioning.
- +104 ;;
- +105 ;;NOTE: VA is prohibited by statute from paying compensation for a disability
- +106 ;;that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on
- +107 ;;direct service connection, secondary service connection, or aggravation by
- +108 ;;a service-connected condition. Therefore, when alcohol or drug abuse
- +109 ;;accompanies or is associated with another mental disorder, separate, to
- +110 ;;the extent possible, the effects of the alcohol or drug abuse from the effects
- +111 ;;of the other mental disorder(s). If it is not possible to separate the effects,
- +112 ;;explain why.
- +113 ;;
- +114 ;;F. Global Assessment of Functioning (GAF):
- +115 ;;
- +116 ;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
- +117 ;;by BVA REMAND or specifically requested by the rating specialist. If so,
- +118 ;;include the GAF score and note whether it refers to current functioning.
- +119 ;;A BVA REMAND may also request , in addition to an overall GAF score, that a
- +120 ;;separate GAF score be provided for each mental disorder present when there are
- +121 ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
- +122 ;;If separate GAF scores can be given, an explanation and discussion of
- +123 ;;the rationale is needed. If it is not possible, an explanation as to why not is
- +124 ;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
- +125 ;; which cannot be used to assess the effects of a service-connected condition.)
- +126 ;;
- +127 ;;
- +128 ;;Signature: Date:
- +129 ;;END