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Routine: DVBCWME1

DVBCWME1.m

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  1. DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
  1. ;;2.7;AMIE;**34**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;; Comment on:
  1. ;;
  1. ;; 1. Past Medical History:
  1. ;;
  1. ;; a. Previous hospitalizations and outpatient care.
  1. ;; b. Medical and occupational history from the time between last rating
  1. ;; examination and the present, UNLESS the purpose of this examination
  1. ;; is to ESTABLISH service connection, then the complete medical history
  1. ;; since discharge from military service is required.
  1. ;;
  1. ;; 2. Present Medical, Occupational, and Social History -
  1. ;; over the past one year.
  1. ;;
  1. ;; a. Frequency, severity, and duration of psychiatric symptoms.
  1. ;; b. Length of remissions, to include capacity for adjustment during
  1. ;; periods of remissions.
  1. ;; c. Extent of time lost from work over the past 12 month period and
  1. ;; social impairment. If employed, identify current occupation and
  1. ;; length of time at this job. If unemployed, note in Complaints whether
  1. ;; veteran contends it is due to the effects of a mental disorder.
  1. ;; Further indicate following DIAGNOSIS what factors, and objective
  1. ;; findings support or rebut that contention.
  1. ;; d. Treatments including statement on effectiveness and side effects
  1. ;; experienced.
  1. ;;
  1. ;; 3. Subjective Complaints:
  1. ;;
  1. ;; a. Describe fully.
  1. ;;
  1. ;;C. Examination (Objective Findings):
  1. ;; Address each of the following and fully describe:
  1. ;;
  1. ;; 1. Mental status exam to confirm or establish diagnosis in
  1. ;; accordance with DSM-IV.
  1. ;; 2. Additionally, to allow evaluation by the rating specialist, describe
  1. ;; and fully explain the existence, frequency, and extent of the following
  1. ;; signs and symptoms, or any others present, and relate how they interfere
  1. ;; with employment and social functioning:
  1. ;; a. Impairment of thought process or communication.
  1. ;; b. Delusions, hallucinations and their persistence.
  1. ;; c. Inappropriate behavior cited with examples.
  1. ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
  1. ;; e. Ability to maintain minimal personal hygiene and other basic
  1. ;; activities of daily living.
  1. ;; f. Orientation to person, place and time.
  1. ;; g. Memory loss or impairment (both short and/or long term).
  1. ;; h. Obsessive or ritualistic behavior which interferes with routine
  1. ;; activities (describe with examples).
  1. ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
  1. ;; speech patterns and whether constant or intermittent.
  1. ;; j. Panic attacks noting the severity, duration, frequency and effect
  1. ;; on independent functioning and whether clinically observed or good
  1. ;; evidence of prior clinical or equivalent observation.
  1. ;; k. Depression, depressed mood, or anxiety.
  1. ;; l. Impaired impulse control and its effect on motivation or mood.
  1. ;; m. Sleep impairment and describe extent it interferes with daytime
  1. ;; activities.
  1. ;; n. Other symptoms and the extent to which they interfere with
  1. ;; activities.
  1. ;;
  1. ;;D. Diagnostic Tests:
  1. ;; 1. Provide psychological testing if deemed necessary.
  1. ;; 2. If testing is requested, the results must be reported and considered in
  1. ;; arriving at the diagnosis.
  1. ;; 3. Provide any specific evaluation information required by the rating board
  1. ;; or on BVA Remand (in claims folder).
  1. ;;
  1. ;; a. COMPETENCY: State whether the veteran is capable of managing
  1. ;; his/her benefit payments in the individual's own best interests
  1. ;; (a physical disability which prevents the veteran from attending
  1. ;; to financial matters in person is not a proper basis for a finding
  1. ;; of incompetency unless the veteran is, by reason of that
  1. ;; disability, incapable of directing someone else in handling
  1. ;; the individual's 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 supporting
  1. ;; opinion, if medical literature review was undertaken.
  1. ;; If the requested opinion is medically not ascertainable on exam
  1. ;; or testing, please indicate WHY. If the requested opinion can not
  1. ;; be expressed without resorting to speculation or making improbable
  1. ;; assumptions say so, and explain why. If the opinion asks "...is it
  1. ;; at least as likely as not..?", fully explain the clinical findings
  1. ;; and rationale for the opinion.
  1. ;; 4. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;TOF
  1. ;;E. Diagnosis:
  1. ;; Provide:
  1. ;;
  1. ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
  1. ;; on the examination report.
  1. ;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
  1. ;; represents a progression of the prior diagnosis or development of a new
  1. ;; and separate condition.
  1. ;; 3. If there are multiple mental disorders, delineate to the extent possible
  1. ;; the symptoms associated with each and a discussion of relationship.
  1. ;; 4. Evaluation is based on the effects of the signs and symptoms on
  1. ;; occupational and social functioning.
  1. ;;
  1. ;;NOTE: VA is prohibited by statute from paying compensation for a disability
  1. ;;that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on
  1. ;;direct service connection, secondary service connection, or aggravation by
  1. ;;a service-connected condition. Therefore, when alcohol or drug abuse
  1. ;;accompanies or is associated with another mental disorder, separate, to
  1. ;;the extent possible, the effects of the alcohol or drug abuse from the effects
  1. ;;of the other mental disorder(s). If it is not possible to separate the effects,
  1. ;;explain why.
  1. ;;
  1. ;;F. Global Assessment of Functioning (GAF):
  1. ;;
  1. ;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
  1. ;;by BVA REMAND or specifically requested by the rating specialist. If so,
  1. ;;include the GAF score and note whether it refers to current functioning.
  1. ;;A BVA REMAND may also request , in addition to an overall GAF score, that a
  1. ;;separate GAF score be provided for each mental disorder present when there are
  1. ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
  1. ;;If separate GAF scores can be given, an explanation and discussion of
  1. ;;the rationale is needed. If it is not possible, an explanation as to why not is
  1. ;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
  1. ;; which cannot be used to assess the effects of a service-connected condition.)
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END