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Routine: DVBCWPD1

DVBCWPD1.m

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  1. DVBCWPD1 ;ALB/ESW PTSD WKS TEXT - 1 ; 1/17/01 3:16pm
  1.  ;;2.7;AMIE;**34**;Apr 10, 1995
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;A. Identifying Information
  1.  ;;
  1.  ;;- age
  1.  ;;- ethnic background
  1.  ;;- era of military service
  1.  ;;- reason for referral (original exam to establish PTSD diagnosis and related
  1.  ;;  psychosocial impairment; re-evaluation of status of existing service-
  1.  ;;  connected PTSD condition)
  1.  ;;
  1.  ;;B. Sources of Information
  1.  ;;
  1.  ;;   * records reviewed (C-file, DD-214, medical records, other documentation)
  1.  ;;   * review of social-industrial survey completed by social worker
  1.  ;;   * statements from collaterals
  1.  ;;   * administration of psychometric tests and questionnaires (identify here)
  1.  ;; 
  1.  ;;C. Review of Medical Records:
  1.  ;;1. Past Medical History:
  1.  ;;
  1.  ;;   a. Previous hospitalizations and outpatient care.
  1.  ;;   b. Complete medical history is required, including history since discharge
  1.  ;;      from military service.
  1.  ;;   c. Review of Claims Folder is required on initial exams to establish or
  1.  ;;      rule out the diagnosis.
  1.  ;;
  1.  ;;2. Present Medical History - over the past one year.
  1.  ;;
  1.  ;;   a. Frequency,severity and duration of medical and psychiatric symptoms.
  1.  ;;   b. Length of remissions, to include capacity for adjustment during periods
  1.  ;;      of remissions.
  1.  ;;
  1.  ;;D. Examination (Objective Findings):
  1.  ;;    Address each of the following and fully describe:
  1.  ;;
  1.  ;;    History (Subjective Complaints):
  1.  ;;     Comment on:
  1.  ;;
  1.  ;;       Preliminary History (refer to social-industrial survey if completed)
  1.  ;;
  1.  ;;       * describe family structure and environment where raised (identify
  1.  ;;         constellation of family members and quality of relationships)
  1.  ;;TOF
  1.  ;;       * quality of peer relationships and social adjustment (e.g., activities,
  1.  ;;         achievements, athletic and/or extracurricular involvements, sexual
  1.  ;;         involvement, etc.)
  1.  ;;       * education obtained and performance in school
  1.  ;;       * employment
  1.  ;;       * legal infractions
  1.  ;;       * delinquency or behavior conduct disturbances
  1.  ;;       * substance use patterns
  1.  ;;       * significant medical problems and treatments obtained
  1.  ;;       * family psychiatric history
  1.  ;;       * exposure to traumatic stressors (see CAPS trauma assessment checklist)
  1.  ;;       * summary assessment of psychosocial adjustment and progression through
  1.  ;;         developmental milestones (performance in employment or schooling,
  1.  ;;         routine responsibilities of self-care, family role functioning,
  1.  ;;         physical health, social/interpersonal relationship, recreation/leisure
  1.  ;;         pursuits).
  1.  ;;
  1.  ;;       Military History
  1.  ;;
  1.  ;;       * branch of service (enlisted or drafted)
  1.  ;;       * dates of service
  1.  ;;       * dates and location of war zone duty and number of months stationed
  1.  ;;         in war zone
  1.  ;;       * Military Occupational Specialty (describe nature and duration of job(s)
  1.  ;;         in war zone
  1.  ;;       * highest rank obtained during service ( rank at discharge if different)
  1.  ;;       * type of discharge from military
  1.  ;;       * describe routine combat stressors veterans was exposed to
  1.  ;;        (refer to Combat Scale)
  1.  ;;       * combat wounds sustained (describe)
  1.  ;;       * CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED
  1.  ;;         PARTICULARLY TRAUMATIC.
  1.  ;;         Clearly describe the stressor. Particularly if the stressor is a type
  1.  ;;         of personal assault, including sexual assault, provide information,
  1.  ;;         with examples, if possible.
  1.  ;;       * indicate overall level of traumatic stress exposure
  1.  ;;         (high, moderate,low) based on frequency and severity of incident
  1.  ;;         exposure
  1.  ;;       * citations or medals received
  1.  ;;       * disciplinary infractions or other adjustment problems during military
  1.  ;;
  1.  ;;NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
  1.  ;;medical evidence establishing a clear diagnosis of the condition that conforms
  1.  ;;to the diagnostic criteria of DSM-IV, credible supporting evidence that
  1.  ;;the claimed in-service stressor actually occurred, and a link, established by
  1.  ;;medical evidence, between current symptomatology and the claimed in-service 
  1.  ;;stressor. It is the responsibility of the examiner to indicate the traumatic
  1.  ;;stressor leading to PTSD, if he or she makes the diagnosis of PTSD.
  1.  ;;  Crucial in this description are specific details of the stressor, with names,
  1.  ;;  dates, and places linked to the stressor, so that the rating specialist can
  1.  ;;  confirm that the cited stressor occurred during active duty.
  1.  ;;
  1.  ;;A diagnosis of PTSD cannot be adequately documented or ruled out without
  1.  ;;obtaining a detailed military history and reviewing the claims folder. 
  1.  ;;This means that initial review of the folder prior to examination, the history
  1.  ;;and examination itself, and the dictation for an examination initially
  1.  ;;establishing PTSD will often require more time than for examinations of other
  1.  ;;disorders.
  1.  ;;
  1.  ;;   Post-Military Trauma History (refer to social-industrial survey if completed)
  1.  ;;
  1.  ;;   * describe post-military traumatic events (see CAPS trauma assessment
  1.  ;;     checklist)
  1.  ;;   * describe psychosocial consequences of post-military trauma exposure(s)
  1.  ;;     (treatment received, disruption to work, adverse health consequences)
  1.  ;;
  1.  ;;   Post-Military Psychosocial Adjustment ( refer to social-industrial survey
  1.  ;;   if completed)
  1.  ;;
  1.  ;;   * legal history (DWIs, arrests, time spent in jail)
  1.  ;;   * educational accomplishment
  1.  ;;   * employment history (describe periods of employment and reasons)
  1.  ;;   * marital and family relationships ( including quality of relationships with
  1.  ;;     children)
  1.  ;;   * degree and quality of social relationships
  1.  ;;   * activities and leisure pursuits
  1.  ;;   * problematic substance abuse (lifetime and current)
  1.  ;;   * significant medical disorders (resulting pain or disability; current
  1.  ;;     medications)
  1.  ;;   * treatment history for significant medical conditions, including 
  1.  ;;     hospitalizations
  1.  ;;   * history of inpatient and/or outpatient psychiatric care (dates and
  1.  ;;     conditions treated)
  1.  ;;   * history of assaultiveness
  1.  ;;   * history of suicide attempts
  1.  ;;   * summary statement of current psychosocial functional status (performance
  1.  ;;     in employment or schooling, routine responsibilities of self care,
  1.  ;;     family role functioning, physical health, social/interpersonal
  1.  ;;     relationships, recreation/leisure pursuits)
  1.  ;;
  1.  ;;E. Mental Status Examination
  1.  ;;
  1.  ;;   Conduct a BRIEF mental status examination aimed at screening for DSM-IV
  1.  ;;   mental disorders. Describe and fully explain the existence, frequency and
  1.  ;;   extent of the following signs and symptoms, or any others present, and
  1.  ;;   relate how they interfere with employment and social functioning:
  1.  ;;
  1.  ;;   * Impairment of thought process or communication.
  1.  ;;   * Delusions, hallucinations and their persistence.
  1.  ;;   * Eye Contact, interaction in session, and inappropriate behavior cited
  1.  ;;     with examples.
  1.  ;;   * Suicidal or homicidal thoughts, ideations or plans or intent.
  1.  ;;   * Ability to maintain minimal personal hygiene and other basic activities
  1.  ;;     of daily living.
  1.  ;;   * Orientation to person, place, and time.
  1.  ;;   * Memory loss, or impairment (both short and long-term).
  1.  ;;   * Obsessive or ritualistic behavior which interferes with routine activities
  1.  ;;     and describe any found.
  1.  ;;   * Rate and flow of speech and note any irrelevant, illogical, or obscure
  1.  ;;     speech patterns and whether constant or intermittent.
  1.  ;;   * Panic attacks noting the severity, duration, frequency, and effect on
  1.  ;;     independent functioning and whether clinically observed or good evidence
  1.  ;;     of prior clinical or equivalent observation is shown.
  1.  ;;   * Depression, depressed mood or anxiety.
  1.  ;;   * Impaired impulse control and its effect on motivation or mood.
  1.  ;;   * Sleep impairment and describe extent it interferes with daytime activities.
  1.  ;;   * Other disorders or symptoms and the extent they interfere with activities,
  1.  ;;     particularly:
  1.  ;;
  1.  ;;     - mood disorders ( especially major depression and dysthymia)
  1.  ;;     - substance use disorders (especially alcohol use disorders)
  1.  ;;     - anxiety disorders (especially panic disorder, obsessive-compulsive
  1.  ;;       disorder, generalized anxiety disorder)
  1.  ;;     - somatoform disorder
  1.  ;;     - personality disorders (especially antisocial personality disorder
  1.  ;;       and borderline personality disorder)
  1.  ;;
  1.  ;;Specify onset and duration of symptoms as acute, chronic, or with delayed onset.