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Routine: DVBCWPF2

DVBCWPF2.m

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  1. DVBCWPF2 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ; 05/18/2006 11:00am
  1.  ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
  1.  ;Per VHA Directive 10-92-142, this routine should not be modified
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;F.  Assessment of PTSD
  1.  ;;
  1.  ;;    - identify the primary stressor or stressors
  1.  ;;    - state whether or not the veteran meets the DSM-IV stressor criterion
  1.  ;;    - identify behavioral, cognitive, social, affective, or somatic change(s)
  1.  ;;      veteran attributes to stress exposure
  1.  ;;    - describe specific PTSD symptoms present (symptoms of trauma
  1.  ;;      re-experiencing, avoidance/numbing, heightened physiological arousal,
  1.  ;;      and associated features [e.g., disillusionment and demoralization])
  1.  ;;    - specify onset, duration, typical frequency, and severity of symptoms
  1.  ;;    - state whether or not the current symptoms are linked to the identified
  1.  ;;      stressor or stressors
  1.  ;;
  1.  ;;G.  Psychometric Testing Results
  1.  ;;
  1.  ;;    - provide psychological testing if deemed necessary.
  1.  ;;    - provide specific evaluation information required by the rating board or
  1.  ;;      on a BVA Remand.
  1.  ;;    - comment on validity of psychological test results
  1.  ;;    - provide scores for PTSD psychometric assessments administered
  1.  ;;TOF
  1.  ;;    - state whether PTSD psychometric measures are consistent or inconsistent
  1.  ;;      with a diagnosis of PTSD, based on normative data and established
  1.  ;;      "cutting scores" (cutting scores that are consistent with or supportive
  1.  ;;      of a PTSD diagnosis are as follows: PCL - not less than 50;
  1.  ;;      Mississippi Scale - not less than 107; MMPI PTSD subscale a score
  1.  ;;      greater than 28; MMPI code type: 2-8 or 2-7-8)
  1.  ;;    - state degree of severity of PTSD symptoms based on psychometric data
  1.  ;;      (mild, moderate, or severe)
  1.  ;;    - describe findings from psychological tests measuring other than
  1.  ;;      PTSD (MMPI, etc.)
  1.  ;;
  1.  ;;H.  Diagnosis:
  1.  ;;
  1.  ;;    1.  The Diagnosis must conform to DSM-IV and be supported by the findings
  1.  ;;        on the examination report.
  1.  ;;    2.  If there are multiple mental disorders, discuss the relationship with
  1.  ;;        PTSD.
  1.  ;;    3.  The evaluation is based on the effects of the signs and symptoms on
  1.  ;;        occupational and social functioning.
  1.  ;;
  1.  ;;   NOTE:  VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
  1.  ;;   for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
  1.  ;;   However, when a veteran's alcohol or drug abuse disability is secondary to
  1.  ;;   or is caused or aggravated by a primary service-connected disorder, the  
  1.  ;;   veteran may be entitled to compensation.  See Allen v. Principi, 237 F.3d
  1.  ;;   1368, 1381 (Fed. Cir. 2001).  Therefore, it is important to determine the
  1.  ;;   relationship, if any, between a service-connected disorder and a disability
  1.  ;;   resulting from the veteran's alcohol or drug abuse.  Unless alcohol or drug
  1.  ;;   abuse is secondary to or is caused or aggravated by another mental disorder,
  1.  ;;   you should separate, to the extent possible, the effects of the alcohol or
  1.  ;;   drug abuse from the effects of the other mental disorder(s).  If it is not
  1.  ;;   possible to separate the effects in such cases, please explain why.
  1.  ;;
  1.  ;;I.  Diagnostic Status
  1.  ;;
  1.  ;;    -   Axis I disorders
  1.  ;;    -   Axis II disorders
  1.  ;;    -   Axis III disorders
  1.  ;;    -   Axis IV (psychosocial and environmental problems)
  1.  ;;    -   Axis V (GAF score - current)
  1.  ;;
  1.  ;;J.  Global Assessment of Functioning (GAF):
  1.  ;;
  1.  ;;    NOTE: The complete multi-axial format as specified by DSM-IV may be required
  1.  ;;    by BVA REMAND or specifically requested by the rating specialist.  If so,
  1.  ;;    include the GAF score and note whether it refers to current functioning.
  1.  ;;    A BVA REMAND may also request, in addition to an overall GAF score,
  1.  ;;    that a separate GAF score be provided for each mental disorder present when
  1.  ;;    there are multiple Axis I or Axis II diagnoses and not all are service-
  1.  ;;    connected.  If separate GAF scores can be given, an explanation and
  1.  ;;TOF
  1.  ;;    discussion of the rationale is needed.  If it is not possible, an
  1.  ;;    explanation as to why not is needed.  (See the above note pertaining to
  1.  ;;    alcohol or drug abuse.)
  1.  ;;
  1.  ;;    DSM-IV is only for application form 11/7/96 on.  Therefore, when
  1.  ;;    applicable note whether the diagnosis for PTSD was supportable under
  1.  ;;    DSM-III-R prior to that date.
  1.  ;;
  1.  ;;K.  Capacity to Manage Financial Affairs
  1.  ;;
  1.  ;;    Mental competency, for VA benefits purposes, refers only to the ability
  1.  ;;    of the veteran to manage VA benefit payments in his or her own best
  1.  ;;    interest, and not to any other subject.  Mental incompetency,
  1.  ;;    for VA benefits purposes, means that the veteran, because of injury
  1.  ;;    or disease, is not capable of managing benefit payments in his or her
  1.  ;;    best interest.  In order to assist raters in making a legal determination
  1.  ;;    as to competency, please address the following:
  1.  ;;
  1.  ;;       What is the impact of injury or disease on the veteran's ability
  1.  ;;       to manage his or her financial affairs, including consideration
  1.  ;;       of such things as knowing the amount of his or her VA benefit
  1.  ;;       payment, knowing the amounts and types of bills owed monthly,
  1.  ;;       and handling the payment prudently?  Does the veteran handle
  1.  ;;       his or her money and pay the bills?
  1.  ;;
  1.  ;;       Based on your examination, do you believe that the veteran is
  1.  ;;       capable of managing his or her financial affairs?
  1.  ;;       Please provide examples to support your conclusion.
  1.  ;;
  1.  ;;       If you believe a Social Work Service assessment is needed before
  1.  ;;       you can give your opinion on the veteran's ability to manage his
  1.  ;;       or her financial affairs, please explain why.
  1.  ;;
  1.  ;;L.  Other Opinion:
  1.  ;;
  1.  ;;    Furnish any other specific opinion requested by the rating
  1.  ;;    board or BVA remand (furnish the complete rationale and citation of medical
  1.  ;;    texts or treatise supporting opinion, if medical literature review was
  1.  ;;    undertaken).  If the requested opinion is medically not ascertainable
  1.  ;;    on exam or testing please state why.  If the requested opinion cannot be
  1.  ;;    expressed without resorting to speculation or making improbable assumptions
  1.  ;;    say so, and explain why.  If the opinion asks "...is it at least as likely
  1.  ;;    as not..", fully explain the clinical findings and rationale for the
  1.  ;;    opinion.
  1.  ;;
  1.  ;;M.  Integrated Summary and Conclusions
  1.  ;;
  1.  ;;    - Describe changes in psychosocial functional status and quality of life
  1.  ;;      following trauma exposure (performance in employment or schooling,
  1.  ;;      routine responsibilities of self care, family role functioning, physical
  1.  ;;      health, social/interpersonal relationships, recreation/leisure pursuits)
  1.  ;;TOF
  1.  ;;    - Describe linkage between PTSD symptoms and aforementioned changes in
  1.  ;;      impairment in functional status and quality of life. 
  1.  ;;      Particularly in cases where a veteran is unemployed, specific 
  1.  ;;      details about the effects of PTSD and its symptoms on employment
  1.  ;;      are especially important.
  1.  ;;    - If possible, describe extent to which disorders other than PTSD
  1.  ;;      (e.g., substance use disorders) are independently responsible for
  1.  ;;      impairment in psychosocial adjustment and quality of life.  If this is
  1.  ;;      not possible, explain why (e.g., substance use had onset after PTSD 
  1.  ;;      and clearly is a means of coping with PTSD symptoms).
  1.  ;;
  1.  ;;    - If possible, describe pre-trauma risk factors or characteristics that
  1.  ;;      may have rendered the veteran vulnerable to developing PTSD subsequent
  1.  ;;      to trauma exposure.
  1.  ;;    - If possible, state prognosis for improvement of psychiatric condition
  1.  ;;      and impairments in functional status.
  1.  ;;    - Comment on whether the veteran is capable of managing his/her
  1.  ;;      benefit payments in his/her own best interest.