DVBCWME7 ;BPOIFO/RLC - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 12/26/06 2:23pm
;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
;Per VHA Directive 10-92-142, this routine should not be modified
;
TXT ;
;;
;;The following health care providers can perform initial examinations for
;;Mental Disorders:
;;a board-certified or board "eligible" psychiatrist;
;;a licensed doctorate-level psychologist;
;;a doctorate-level mental health provider under the close supervision of a
;;board-certified or board eligible psychiatrist or licensed doctorate-level
;;psychologist;
;;a psychiatry resident under close supervision of a board-certified or
;;board eligible psychiatrist or licensed doctorate-level psychologist; or
;;a clinical or counseling psychologist completing a one-year internship
;;or residency (for purposes of a doctorate-level degree) under close
;;supervision of a board-certified or eligible psychiatrist or licensed
;;doctorate-level psychologist.
;;
;;The following health care providers can perform review examinations for
;;Mental Disorders:
;;a board-certified or board "eligible" psychiatrist;
;;a licensed doctorate-level psychologist;
;;a doctorate-level mental health provider under close supervision of a
;;board-certified or board eligible psychiatrist or licensed doctorate-level
;;psychologist;
;;a psychiatry resident under close supervision of a board-certified or board
;;eligible psychiatrist or licensed doctorate-level psychologist;
;;a clinical or counseling psychologist completing a one-year internship or
;;residency (for purposes of a doctorate-level degree) under close
;;supervision of a board-certified or board eligible psychiatrist or licensed
;;doctorate-level psychologist;
;;a licensed clinical social worker (LCSW); a nurse practitioner, a clinical
;;nurse specialist or physician assistant, if they are clinically privileged
;;to perform activities required for C&P mental disorder examinations, under
;;the close supervision of a board-certified or board eligible psychiatrist
;;or licensed doctorate-level psychologist.
;;
;;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,
;; occupational and social history pre-military, military and since
;; discharge from military service is required.
;; c. Substance use and its consequences.
;;
;; 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. Social functioning and adjustment.
;; d. Extent of time lost from work over the past 12 month period.
;; 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.
;; e. 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 that interferes with routine
;; activities.
;; 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 incompetence, 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?
;;
;; - 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 cannot
;; 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.
;;
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWME7 8509 printed Dec 13, 2024@01:52:38 Page 2
DVBCWME7 ;BPOIFO/RLC - MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS) ; 12/26/06 2:23pm
+1 ;;2.7;AMIE;**118**;Apr 10, 1995;Build 3
+2 ;Per VHA Directive 10-92-142, this routine should not be modified
+3 ;
TXT ;
+1 ;;
+2 ;;The following health care providers can perform initial examinations for
+3 ;;Mental Disorders:
+4 ;;a board-certified or board "eligible" psychiatrist;
+5 ;;a licensed doctorate-level psychologist;
+6 ;;a doctorate-level mental health provider under the close supervision of a
+7 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
+8 ;;psychologist;
+9 ;;a psychiatry resident under close supervision of a board-certified or
+10 ;;board eligible psychiatrist or licensed doctorate-level psychologist; or
+11 ;;a clinical or counseling psychologist completing a one-year internship
+12 ;;or residency (for purposes of a doctorate-level degree) under close
+13 ;;supervision of a board-certified or eligible psychiatrist or licensed
+14 ;;doctorate-level psychologist.
+15 ;;
+16 ;;The following health care providers can perform review examinations for
+17 ;;Mental Disorders:
+18 ;;a board-certified or board "eligible" psychiatrist;
+19 ;;a licensed doctorate-level psychologist;
+20 ;;a doctorate-level mental health provider under close supervision of a
+21 ;;board-certified or board eligible psychiatrist or licensed doctorate-level
+22 ;;psychologist;
+23 ;;a psychiatry resident under close supervision of a board-certified or board
+24 ;;eligible psychiatrist or licensed doctorate-level psychologist;
+25 ;;a clinical or counseling psychologist completing a one-year internship or
+26 ;;residency (for purposes of a doctorate-level degree) under close
+27 ;;supervision of a board-certified or board eligible psychiatrist or licensed
+28 ;;doctorate-level psychologist;
+29 ;;a licensed clinical social worker (LCSW); a nurse practitioner, a clinical
+30 ;;nurse specialist or physician assistant, if they are clinically privileged
+31 ;;to perform activities required for C&P mental disorder examinations, under
+32 ;;the close supervision of a board-certified or board eligible psychiatrist
+33 ;;or licensed doctorate-level psychologist.
+34 ;;
+35 ;;A. Review of Medical Records:
+36 ;;
+37 ;;B. Medical History (Subjective Complaints):
+38 ;;
+39 ;; Comment on:
+40 ;;
+41 ;; 1. Past Medical History:
+42 ;;
+43 ;; a. Previous hospitalizations and outpatient care.
+44 ;; b. Medical and occupational history from the time between last rating
+45 ;; examination and the present, unless the purpose of this examination
+46 ;; is to ESTABLISH service connection, then the complete medical,
+47 ;; occupational and social history pre-military, military and since
+48 ;; discharge from military service is required.
+49 ;; c. Substance use and its consequences.
+50 ;;
+51 ;; 2. Present Medical, Occupational, and Social History -
+52 ;; over the past one year.
+53 ;;
+54 ;; a. Frequency, severity, and duration of psychiatric symptoms.
+55 ;; b. Length of remissions, to include capacity for adjustment during
+56 ;; periods of remissions.
+57 ;; c. Social functioning and adjustment.
+58 ;; d. Extent of time lost from work over the past 12 month period.
+59 ;; If employed, identify current occupation and length of time at
+60 ;; this job. If unemployed, note in complaints whether veteran
+61 ;; contends it is due to the effects of a mental disorder.
+62 ;; Further indicate following DIAGNOSIS what factors, and objective
+63 ;; findings support or rebut that contention.
+64 ;; e. Treatments including statement on effectiveness and side effects
+65 ;; experienced.
+66 ;;
+67 ;; 3. Subjective Complaints:
+68 ;;
+69 ;; a. Describe fully.
+70 ;;
+71 ;;C. Examination (Objective Findings):
+72 ;;
+73 ;; Address each of the following and fully describe:
+74 ;;
+75 ;; 1. Mental status exam to confirm or establish diagnosis in
+76 ;; accordance with DSM-IV.
+77 ;; 2. Additionally, to allow evaluation by the rating specialist, describe
+78 ;; and fully explain the existence, frequency, and extent of the following
+79 ;; signs and symptoms, or any others present, and relate how they interfere
+80 ;; with employment and social functioning:
+81 ;;
+82 ;; a. Impairment of thought process or communication.
+83 ;; b. Delusions, hallucinations and their persistence.
+84 ;; c. Inappropriate behavior cited with examples.
+85 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
+86 ;; e. Ability to maintain minimal personal hygiene and other basic
+87 ;; activities of daily living.
+88 ;; f. Orientation to person, place and time.
+89 ;; g. Memory loss or impairment (both short and/or long term).
+90 ;; h. Obsessive or ritualistic behavior that interferes with routine
+91 ;; activities.
+92 ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
+93 ;; speech patterns and whether constant or intermittent.
+94 ;; j. Panic attacks noting the severity, duration, frequency and effect
+95 ;; on independent functioning and whether clinically observed or good
+96 ;; evidence of prior clinical or equivalent observation.
+97 ;; k. Depression, depressed mood, or anxiety.
+98 ;; l. Impaired impulse control and its effect on motivation or mood.
+99 ;; m. Sleep impairment and describe extent it interferes with daytime
+100 ;; activities.
+101 ;; n. Other symptoms and the extent to which they interfere with
+102 ;; activities.
+103 ;;
+104 ;;D. Diagnostic Tests:
+105 ;;
+106 ;; 1. Provide psychological testing if deemed necessary.
+107 ;; 2. If testing is requested, the results must be reported and considered in
+108 ;; arriving at the diagnosis.
+109 ;; 3. Provide any specific evaluation information required by the rating board
+110 ;; or on BVA Remand (in claims folder).
+111 ;;
+112 ;; a. CAPACITY TO MANAGE FINANCIAL AFFAIRS Mental competency, for
+113 ;; VA benefits purposes, refers only to the ability of the veteran
+114 ;; to manage VA benefit payments in his or her own best interest,
+115 ;; and not to any other subject. Mental incompetence, for VA benefits
+116 ;; purposes, means that the veteran, because of injury or disease,
+117 ;; is not capable of managing benefit payments in his or her best
+118 ;; interest. In order to assist raters in making a legal determination
+119 ;; as to competency, please address the following:
+120 ;; - What is the impact of injury or disease on the veteran's ability
+121 ;; to manage his or her financial affairs, including consideration
+122 ;; of such things as knowing the amount of his or her VA benefit
+123 ;; payment, knowing the amounts and types of bills owed monthly,
+124 ;; and handling the payment prudently? Does the veteran handle
+125 ;; the money and pay the bills?
+126 ;;
+127 ;; - Based on your examination, do you believe that the veteran is
+128 ;; capable of managing his or her financial affairs?
+129 ;; - Please provide examples to support your conclusion.
+130 ;;
+131 ;; If you believe a Social Work Service assessment is needed before
+132 ;; you can give your opinion on the veteran's ability to manage his
+133 ;; or her financial affairs, please explain why.
+134 ;;
+135 ;; b. Other Opinion: Furnish any other specific opinion requested
+136 ;; by the rating board or BVA Remand furnishing the complete
+137 ;; rationale and citation of medical texts or treatise supporting
+138 ;; opinion, if medical literature review was undertaken.
+139 ;; If the requested opinion is medically not ascertainable on exam
+140 ;; or testing, please indicate why. If the requested opinion cannot
+141 ;; be expressed without resorting to speculation or making improbable
+142 ;; assumptions say so, and explain why. If the opinion asks "...is it
+143 ;; at least as likely as not..?", fully explain the clinical findings
+144 ;; and rationale for the opinion.
+145 ;;
+146 ;; 4. Include results of all diagnostic and clinical tests conducted
+147 ;; in the examination report.
+148 ;;
