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Routine: DVBCWME5

DVBCWME5.m

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DVBCWME5 ;BPOIFO/ESW - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 10/1/02 5:39pm

 ;;2.7;AMIE;**46**;Apr 10, 1995

 ;Per VHA Directive 10-92-142, this routine should not be modified

 ;

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. CAPACITY TO MANAGE FINANCIAL AFFAIRS

 ;;

 ;;           Mental competency, for VA benefits purposes, refers only to

 ;;           the ability of the veteran to manage VA benefit payments in his or

 ;;           her own best interest, and not to any other subject. Mental

 ;;           incompetency, for VA benefits purposes, means that the veteran,

 ;;           because of injury or disease, is not capable of managing benefit

 ;;           payments in his or her best interest. In order to assist raters in

 ;;           making a legal determination as to competency,

 ;;           please address the following:

 ;;                What is the impact of injury or disease on the veteran's ability

 ;;                to manage his or her financial affairs, including consideration

 ;;                of such things as knowing the amount of his or her VA benefit

 ;;                payment, knowing the amounts and types of bills owed monthly,

 ;;                and handling the payment prudently? Does the veteran handle

 ;;                the money and pay the bills himself or herself?

 ;;

 ;;                Based on your examination, do you believe that the veteran is

 ;;                capable of managing his or her financial affairs?

 ;;                Please provide examples to support your conclusion.

 ;;

 ;;                If you believe a Social Work Service assessment is needed before

 ;;                you can give your opinion on the veteran's ability to manage his

 ;;                or her financial affairs, please explain why.

 ;;

 ;;           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.

 ;;

 ;;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, 38 U.S.C. 1110, from paying compensation

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

 ;;However, when a veteran's alcohol or drug abuse disability is secondary to

 ;;or is caused or aggravated by a primary service-connected disorder, the  

 ;;veteran may be entitled to compensation.  See Allen v. Principi, 237 F.3d

 ;;1368, 1381 (Fed. Cir. 2001).  Therefore, it is important to determine the

 ;;relationship, if any, between a service-connected disorder and a disability

 ;;resulting from the veteran's alcohol or drug abuse.  Unless alcohol or drug

 ;;abuse is secondary to or is caused or aggravated by another mental disorder,

 ;;you should 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 in such cases, please 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.)

 ;;

 ;;

 ;;Signature:                                        Date:

 ;;END