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DVBCWPF1.m

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DVBCWPF1 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ;05/18/2006 11:00am

 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6

 ;Per VHA Directive 10-92-142, this routine should not be modified

 ;

TXT ;

 ;;

 ;;The following health care providers can perform initial examinations for PTSD:

 ;;

 ;;   - 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 board eligible psychiatrist or

 ;;     licensed doctorate-level psychologist.

 ;;

 ;;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.

 ;;TOF

 ;;        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:

 ;;

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

 ;;

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

 ;;         constellation of family members and quality of relationships)

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

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

 ;;         involvements, etc.)

 ;;       - education obtained and performance in school

 ;;       - employment

 ;;       - legal infractions

 ;;       - delinquency or behavior conduct disturbances

 ;;       - substance use and consequences of substance use

 ;;       - 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

 ;;       - substance use and consequences of substance use

 ;;       - combat wounds sustained (describe)

 ;;       - clearly describe the specific stressor event(s) veteran considers

 ;;         particularly traumatic, 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

 ;;TOF

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

 ;;   medical evidence establishing a 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 describe

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

 ;;   of PTSD.

 ;;

 ;;   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.  Ninety minutes to two hours on an

 ;;   initial exam is normal.

 ;;

 ;;     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 unemployment and reasons)

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

 ;;     children)

 ;;   - degree and quality of social relationships

 ;;   - activities and leisure pursuits

 ;;   - substance use and consequences of substance use

 ;;   - 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).

 ;;TOF

 ;;E.  Mental Status Examination

 ;;

 ;;    Conduct a 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 that interferes with routine activities

 ;;    - 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