©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWPE1 ;ESW/ PTSD WKS TEXT - 1 ; 9 Oct 2000
;;2.7;AMIE;**34**;Apr 10, 1995
;
;
TXT ;
;;
;;A. Review of Medical Records
;;
;;B. Medical History since last exam:
;; Comments on:
;;
;; 1. Hospitalizations and outpatient care from the time between last
;; rating examination to 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. Frequency, severity and duration of psychiatric symptoms.
;; 3. Length of remissions from psychiatric symptoms, to include capacity
;; for adjustment during periods of remissions.
;; 4. Treatments including statement on effectiveness and side effects
;; experienced.
;; 5. SUBJECTIVE COMPLAINTS: Describe fully.
;;
;;C. Psychosocial Adjustment since the last exam
;;
;; * legal history (DWIs, arrests, time spent in jail)
;; * educational accomplishment
;; * extent of time list 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.
;; * marital and family relationships ( including quality of relationships with
;; spouse and children)
;; * degree and quality of social relationships
;; * activities and leisure pursuits
;; * problematic substance abuse
;; * significant medical disorders (resulting pain or disability; current
;; medications)
;; * history of violence/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
;; relationship, recreation/leisure pursuits)
;;TOF
;;D. Mental Status Examination
;;
;; Conduct a BRIEF mental status examinaton 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 disorders
;; - personality disorders (especially antisocial personality disorder
;; and borderline personality disorder)
;;