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Routine: DVBCWPD1

DVBCWPD1.m

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DVBCWPD1 ;ALB/ESW PTSD WKS TEXT - 1 ; 1/17/01 3:16pm

 ;;2.7;AMIE;**34**;Apr 10, 1995

 ;

TXT ;

 ;;

 ;;A. Identifying Information

 ;;

 ;;- age

 ;;- ethnic background

 ;;- era of military service

 ;;- reason for referral (original exam to establish PTSD diagnosis and related

 ;;  psychosocial impairment; re-evaluation of status of existing service-

 ;;  connected PTSD condition)

 ;;

 ;;B. Sources of Information

 ;;

 ;;   * records reviewed (C-file, DD-214, medical records, other documentation)

 ;;   * review of social-industrial survey completed by social worker

 ;;   * statements from collaterals

 ;;   * administration of psychometric tests and questionnaires (identify here)

 ;; 

 ;;C. Review of Medical Records:

 ;;1. Past Medical History:

 ;;

 ;;   a. Previous hospitalizations and outpatient care.

 ;;   b. Complete medical history is required, including history since discharge

 ;;      from military service.

 ;;   c. Review of Claims Folder is required on initial exams to establish or

 ;;      rule out the diagnosis.

 ;;

 ;;2. Present Medical History - over the past one year.

 ;;

 ;;   a. Frequency,severity and duration of medical and psychiatric symptoms.

 ;;   b. Length of remissions, to include capacity for adjustment during periods

 ;;      of remissions.

 ;;

 ;;D. Examination (Objective Findings):

 ;;    Address each of the following and fully describe:

 ;;

 ;;    History (Subjective Complaints):

 ;;     Comment on:

 ;;

 ;;       Preliminary History (refer to social-industrial survey if completed)

 ;;

 ;;       * describe family structure and environment where raised (identify

 ;;         constellation of family members and quality of relationships)

 ;;TOF

 ;;       * quality of peer relationships and social adjustment (e.g., activities,

 ;;         achievements, athletic and/or extracurricular involvements, sexual

 ;;         involvement, etc.)

 ;;       * education obtained and performance in school

 ;;       * employment

 ;;       * legal infractions

 ;;       * delinquency or behavior conduct disturbances

 ;;       * substance use patterns

 ;;       * significant medical problems and treatments obtained

 ;;       * family psychiatric history

 ;;       * exposure to traumatic stressors (see CAPS trauma assessment checklist)

 ;;       * summary assessment of psychosocial adjustment and progression through

 ;;         developmental milestones (performance in employment or schooling,

 ;;         routine responsibilities of self-care, family role functioning,

 ;;         physical health, social/interpersonal relationship, recreation/leisure

 ;;         pursuits).

 ;;

 ;;       Military History

 ;;

 ;;       * branch of service (enlisted or drafted)

 ;;       * dates of service

 ;;       * dates and location of war zone duty and number of months stationed

 ;;         in war zone

 ;;       * Military Occupational Specialty (describe nature and duration of job(s)

 ;;         in war zone

 ;;       * highest rank obtained during service ( rank at discharge if different)

 ;;       * type of discharge from military

 ;;       * describe routine combat stressors veterans was exposed to

 ;;        (refer to Combat Scale)

 ;;       * combat wounds sustained (describe)

 ;;       * CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED

 ;;         PARTICULARLY TRAUMATIC.

 ;;         Clearly describe the stressor. Particularly if the stressor is a type

 ;;         of personal assault, including sexual assault, provide information,

 ;;         with examples, if possible.

 ;;       * indicate overall level of traumatic stress exposure

 ;;         (high, moderate,low) based on frequency and severity of incident

 ;;         exposure

 ;;       * citations or medals received

 ;;       * disciplinary infractions or other adjustment problems during military

 ;;

 ;;NOTE: Service connection for post-traumatic stress disorder (PTSD) requires

 ;;medical evidence establishing a clear diagnosis of the condition that conforms

 ;;to the diagnostic criteria of DSM-IV, credible supporting evidence that

 ;;the claimed in-service stressor actually occurred, and a link, established by

 ;;medical evidence, between current symptomatology and the claimed in-service 

 ;;stressor. It is the responsibility of the examiner to indicate the traumatic

 ;;stressor leading to PTSD, if he or she makes the diagnosis of PTSD.

 ;;  Crucial in this description are specific details of the stressor, with names,

 ;;  dates, and places linked to the stressor, so that the rating specialist can

 ;;  confirm that the cited stressor occurred during active duty.

 ;;

 ;;A diagnosis of PTSD cannot be adequately documented or ruled out without

 ;;obtaining a detailed military history and reviewing the claims folder. 

 ;;This means that initial review of the folder prior to examination, the history

 ;;and examination itself, and the dictation for an examination initially

 ;;establishing PTSD will often require more time than for examinations of other

 ;;disorders.

 ;;

 ;;   Post-Military Trauma History (refer to social-industrial survey if completed)

 ;;

 ;;   * describe post-military traumatic events (see CAPS trauma assessment

 ;;     checklist)

 ;;   * describe psychosocial consequences of post-military trauma exposure(s)

 ;;     (treatment received, disruption to work, adverse health consequences)

 ;;

 ;;   Post-Military Psychosocial Adjustment ( refer to social-industrial survey

 ;;   if completed)

 ;;

 ;;   * legal history (DWIs, arrests, time spent in jail)

 ;;   * educational accomplishment

 ;;   * employment history (describe periods of employment and reasons)

 ;;   * marital and family relationships ( including quality of relationships with

 ;;     children)

 ;;   * degree and quality of social relationships

 ;;   * activities and leisure pursuits

 ;;   * problematic substance abuse (lifetime and current)

 ;;   * significant medical disorders (resulting pain or disability; current

 ;;     medications)

 ;;   * treatment history for significant medical conditions, including 

 ;;     hospitalizations

 ;;   * history of inpatient and/or outpatient psychiatric care (dates and

 ;;     conditions treated)

 ;;   * history of assaultiveness

 ;;   * history of suicide attempts

 ;;   * summary statement of current psychosocial functional status (performance

 ;;     in employment or schooling, routine responsibilities of self care,

 ;;     family role functioning, physical health, social/interpersonal

 ;;     relationships, recreation/leisure pursuits)

 ;;

 ;;E. Mental Status Examination

 ;;

 ;;   Conduct a BRIEF mental status examination aimed at screening for DSM-IV

 ;;   mental disorders. 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:

 ;;

 ;;   * Impairment of thought process or communication.

 ;;   * Delusions, hallucinations and their persistence.

 ;;   * Eye Contact, interaction in session, and inappropriate behavior cited

 ;;     with examples.

 ;;   * Suicidal or homicidal thoughts, ideations or plans or intent.

 ;;   * Ability to maintain minimal personal hygiene and other basic activities

 ;;     of daily living.

 ;;   * Orientation to person, place, and time.

 ;;   * Memory loss, or impairment (both short and long-term).

 ;;   * Obsessive or ritualistic behavior which interferes with routine activities

 ;;     and describe any found.

 ;;   * Rate and flow of speech and note any irrelevant, illogical, or obscure

 ;;     speech patterns and whether constant or intermittent.

 ;;   * 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 is shown.

 ;;   * Depression, depressed mood or anxiety.

 ;;   * Impaired impulse control and its effect on motivation or mood.

 ;;   * Sleep impairment and describe extent it interferes with daytime activities.

 ;;   * Other disorders or symptoms and the extent they interfere with activities,

 ;;     particularly:

 ;;

 ;;     - mood disorders ( especially major depression and dysthymia)

 ;;     - substance use disorders (especially alcohol use disorders)

 ;;     - anxiety disorders (especially panic disorder, obsessive-compulsive

 ;;       disorder, generalized anxiety disorder)

 ;;     - somatoform disorder

 ;;     - personality disorders (especially antisocial personality disorder

 ;;       and borderline personality disorder)

 ;;

 ;;Specify onset and duration of symptoms as acute, chronic, or with delayed onset.