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Routine: DVBCWME5

DVBCWME5.m

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  1. DVBCWME5 ;BPOIFO/ESW - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 10/1/02 5:39pm
  1.  ;;2.7;AMIE;**46**;Apr 10, 1995
  1.  ;Per VHA Directive 10-92-142, this routine should not be modified
  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.  ;;     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. CAPACITY TO MANAGE FINANCIAL AFFAIRS
  1.  ;;
  1.  ;;           Mental competency, for VA benefits purposes, refers only to
  1.  ;;           the ability of the veteran to manage VA benefit payments in his or
  1.  ;;           her own best interest, and not to any other subject. Mental
  1.  ;;           incompetency, for VA benefits purposes, means that the veteran,
  1.  ;;           because of injury or disease, is not capable of managing benefit
  1.  ;;           payments in his or her best interest. In order to assist raters in
  1.  ;;           making a legal determination as to competency,
  1.  ;;           please address the following:
  1.  ;;                What is the impact of injury or disease on the veteran's ability
  1.  ;;                to manage his or her financial affairs, including consideration
  1.  ;;                of such things as knowing the amount of his or her VA benefit
  1.  ;;                payment, knowing the amounts and types of bills owed monthly,
  1.  ;;                and handling the payment prudently? Does the veteran handle
  1.  ;;                the money and pay the bills himself or herself?
  1.  ;;
  1.  ;;                Based on your examination, do you believe that the veteran is
  1.  ;;                capable of managing his or her financial affairs?
  1.  ;;                Please provide examples to support your conclusion.
  1.  ;;
  1.  ;;                If you believe a Social Work Service assessment is needed before
  1.  ;;                you can give your opinion on the veteran's ability to manage his
  1.  ;;                or her financial affairs, please explain why.
  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.  ;;
  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, 38 U.S.C. 1110, from paying compensation
  1.  ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
  1.  ;;However, when a veteran's alcohol or drug abuse disability is secondary to
  1.  ;;or is caused or aggravated by a primary service-connected disorder, the  
  1.  ;;veteran may be entitled to compensation.  See Allen v. Principi, 237 F.3d
  1.  ;;1368, 1381 (Fed. Cir. 2001).  Therefore, it is important to determine the
  1.  ;;relationship, if any, between a service-connected disorder and a disability
  1.  ;;resulting from the veteran's alcohol or drug abuse.  Unless alcohol or drug
  1.  ;;abuse is secondary to or is caused or aggravated by another mental disorder,
  1.  ;;you should separate, to the extent possible, the effects of the alcohol or
  1.  ;;drug abuse from the effects of the other mental disorder(s).  If it is not
  1.  ;;possible to separate the effects in such cases, please 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.)
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                        Date:
  1.  ;;END