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Routine: DVBCWPE4

DVBCWPE4.m

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  1. DVBCWPE4 ;BP-CIOFO/MM - REVIEW PTSD WORKSHEET TEXT ;3/27/2002
  1.  ;;2.7;AMIE;**43**;Apr 10, 1995
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;A. Review of Medical Records
  1.  ;;
  1.  ;;B. Medical History since last exam:
  1.  ;;     Comments on:
  1.  ;;
  1.  ;;     1. Hospitalizations and outpatient care from the time between last
  1.  ;;        rating examination to the present, UNLESS the purpose of this 
  1.  ;;        examination is to ESTABLISH service connection, then the complete
  1.  ;;        medical history since discharge from military service is required.
  1.  ;;     2. Frequency, severity and duration of psychiatric symptoms.
  1.  ;;     3. Length of remissions from psychiatric symptoms, to include capacity
  1.  ;;        for adjustment during periods of remissions.
  1.  ;;     4. Treatments including statement on effectiveness and side effects
  1.  ;;        experienced.
  1.  ;;     5. SUBJECTIVE COMPLAINTS: Describe fully.
  1.  ;;
  1.  ;;C. Psychosocial Adjustment since the last exam
  1.  ;;
  1.  ;;   1. legal history (DWIs, arrests, time spent in jail)
  1.  ;;   2. educational accomplishment
  1.  ;;   3. extent of time lost from work over the past 12 month period and social
  1.  ;;      impairment. If employed, identify current occupation and length of time
  1.  ;;      at this job.
  1.  ;;       If unemployed, note in COMPLAINTS whether veteran contends it is due to
  1.  ;;       the effects of a mental disorder. Further indicate following DIAGNOSIS
  1.  ;;       what factors, and objective findings support or rebut that contention.
  1.  ;;   4. marital and family relationships ( including quality of relationships with
  1.  ;;      spouse and children)
  1.  ;;   5. degree and quality of social relationships
  1.  ;;   6. activities and leisure pursuits
  1.  ;;   7. problematic substance abuse
  1.  ;;   8. significant medical disorders (resulting pain or disability; current
  1.  ;;      medications)
  1.  ;;   9. history of violence/assaultiveness
  1.  ;;  10. history of suicide attempts
  1.  ;;  11. 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.  ;;      relationship, recreation/leisure pursuits)
  1.  ;;TOF
  1.  ;;D. 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.  ;;   1. Impairment of thought process or communication.
  1.  ;;   2. Delusions, hallucinations and their persistence.
  1.  ;;   3. Eye Contact, interaction in session, and inappropriate behavior cited
  1.  ;;      with examples.
  1.  ;;   4. Suicidal or homicidal thoughts, ideations or plans or intent.
  1.  ;;   5. Ability to maintain minimal personal hygiene and other basic activities
  1.  ;;      of daily living.
  1.  ;;   6. Orientation to person, place, and time.
  1.  ;;   7. Memory loss, or impairment (both short and long-term).
  1.  ;;   8. Obsessive or ritualistic behavior which interferes with routine activities
  1.  ;;      and describe any found.
  1.  ;;   9. Rate and flow of speech and note any irrelevant, illogical, or obscure
  1.  ;;      speech patterns and whether constant or intermittent.
  1.  ;;  10. 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.  ;;  11. Depression, depressed mood or anxiety.
  1.  ;;  12. Impaired impulse control and its effect on motivation or mood.
  1.  ;;  13. Sleep impairment and describe extent it interferes with daytime activities.
  1.  ;;  14. Other disorders or symptoms and the extent they interfere with activities,
  1.  ;;      particularly:
  1.  ;;
  1.  ;;     a. mood disorders (especially major depression and dysthymia)
  1.  ;;     b. substance use disorders (especially alcohol use disorders)
  1.  ;;     c. anxiety disorders (especially panic disorder, obsessive-compulsive
  1.  ;;        disorder, generalized anxiety disorder)
  1.  ;;     d. somatoform disorders
  1.  ;;     e. personality disorders (especially antisocial personality disorder
  1.  ;;        and borderline personality disorder)
  1.  ;;