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Routine: DVBCWPF5

DVBCWPF5.m

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  1. DVBCWPF5 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ;05/18/2006 11:00am
  1.  ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;The following health care providers can perform initial examinations for PTSD:
  1.  ;;
  1.  ;;   - a board certified or board "eligible" psychiatrist;
  1.  ;;   - a licensed doctorate-level psychologist;
  1.  ;;   - a doctorate-level mental health provider under the close supervision
  1.  ;;     of a board certified or board eligible psychiatrist or licensed
  1.  ;;     doctorate-level psychologist;
  1.  ;;   - a psychiatry resident under close supervision of a board certified
  1.  ;;     or board eligible psychiatrist or licensed doctorate-level
  1.  ;;     psychologist; or
  1.  ;;   - a clinical or counseling psychologist completing a one-year internship
  1.  ;;     or residency (for purposes of a doctorate-level degree) under close
  1.  ;;     supervision of a board certified or board eligible psychiatrist or
  1.  ;;     licensed doctorate-level psychologist.
  1.  ;;
  1.  ;;A.  Identifying Information
  1.  ;;
  1.  ;;    - age
  1.  ;;    - ethnic background
  1.  ;;    - era of military service
  1.  ;;    - reason for referral (original exam to establish PTSD diagnosis and
  1.  ;;      related psychosocial impairment; re-evaluation of status of existing
  1.  ;;      service-connected PTSD condition)
  1.  ;;
  1.  ;;B.  Sources of Information
  1.  ;;
  1.  ;;    - records reviewed (C-file, DD-214, medical records, other documentation)
  1.  ;;    - review of social-industrial survey completed by social worker
  1.  ;;    - statements from collaterals
  1.  ;;    - administration of psychometric tests and questionnaires (identify here)
  1.  ;; 
  1.  ;;C.  Review of Medical Records:
  1.  ;;
  1.  ;;    1.  Past Medical History:
  1.  ;;
  1.  ;;        a.  Previous hospitalizations and outpatient care.
  1.  ;;        b.  Complete medical history is required, including history since
  1.  ;;            discharge from military service.
  1.  ;;        c.  Review of Claims Folder is required on initial exams to establish
  1.  ;;            or rule out the diagnosis.
  1.  ;;
  1.  ;;    2.  Present Medical History - over the past one year.
  1.  ;;
  1.  ;;        a.  Frequency, severity and duration of medical and psychiatric
  1.  ;;            symptoms.
  1.  ;;TOF
  1.  ;;        b.  Length of remissions, to include capacity for adjustment during
  1.  ;;            periods of remissions.
  1.  ;;
  1.  ;;D.  Examination (Objective Findings):
  1.  ;;    Address each of the following and fully describe:
  1.  ;;
  1.  ;;    History (Subjective Complaints):
  1.  ;;    Comment on:
  1.  ;;
  1.  ;;         Premilitary History (refer to social-industrial survey if completed)
  1.  ;;
  1.  ;;       - describe family structure and environment where raised (identify
  1.  ;;         constellation of family members and quality of relationships)
  1.  ;;       - quality of peer relationships and social adjustment (e.g., activities,
  1.  ;;         achievements, athletic and/or extracurricular involvements, sexual
  1.  ;;         involvements, etc.)
  1.  ;;       - education obtained and performance in school
  1.  ;;       - employment
  1.  ;;       - legal infractions
  1.  ;;       - delinquency or behavior conduct disturbances
  1.  ;;       - substance use and consequences of substance use
  1.  ;;       - significant medical problems and treatments obtained
  1.  ;;       - family psychiatric history
  1.  ;;       - exposure to traumatic stressors (see CAPS trauma assessment checklist)
  1.  ;;       - summary assessment of psychosocial adjustment and progression through
  1.  ;;         developmental milestones (performance in employment or schooling,
  1.  ;;         routine responsibilities of self-care, family role functioning,
  1.  ;;         physical health, social/interpersonal relationship, recreation/leisure
  1.  ;;         pursuits).
  1.  ;;
  1.  ;;         Military History
  1.  ;;
  1.  ;;       - branch of service (enlisted or drafted)
  1.  ;;       - dates of service
  1.  ;;       - dates and location of war zone duty and number of months stationed
  1.  ;;         in war zone
  1.  ;;       - Military Occupational Specialty (describe nature and duration of job(s)
  1.  ;;         in war zone)
  1.  ;;       - highest rank obtained during service (rank at discharge if different)
  1.  ;;       - type of discharge from military
  1.  ;;       - substance use and consequences of substance use
  1.  ;;       - combat wounds sustained (describe)
  1.  ;;       - clearly describe the specific stressor event(s) veteran considers
  1.  ;;         particularly traumatic, particularly, if the stressor is a type
  1.  ;;         of personal assault, including sexual assault, provide information,
  1.  ;;         with examples, if possible
  1.  ;;       - state whether or not the claimed stressor is related to the veteran's
  1.  ;;         fear of in-service hostile military or terrorist activity
  1.  ;;       - indicate overall level of traumatic stress exposure
  1.  ;;         (high, moderate, low) based on frequency and severity of incident
  1.  ;;         exposure
  1.  ;;       - citations or medals received
  1.  ;;       - disciplinary infractions or other adjustment problems during military
  1.  ;;TOF
  1.  ;;   NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
  1.  ;;   medical evidence establishing a diagnosis of the condition that conforms
  1.  ;;   to the diagnostic criteria of DSM-IV, credible supporting evidence that
  1.  ;;   the claimed in-service stressor actually occurred, and a link, established
  1.  ;;   by medical evidence, between current symptomatology and the claimed
  1.  ;;   in-service stressor.  It is the responsibility of the examiner to describe
  1.  ;;   the traumatic stressor leading to PTSD, if he or she makes the diagnosis
  1.  ;;   of PTSD.
  1.  ;;
  1.  ;;   A diagnosis of PTSD cannot be adequately documented or ruled out without
  1.  ;;   obtaining a detailed military history and reviewing the claims folder. 
  1.  ;;   This means that initial review of the folder prior to examination, the
  1.  ;;   history and examination itself, and the dictation for an examination
  1.  ;;   initially establishing PTSD will often require more time than for 
  1.  ;;   examinations of other disorders.  Ninety minutes to two hours on an
  1.  ;;   initial exam is normal.
  1.  ;;
  1.  ;;     Post-Military Trauma History (refer to social-industrial survey if
  1.  ;;     completed)
  1.  ;;
  1.  ;;   - describe post-military traumatic events (see CAPS trauma assessment
  1.  ;;     checklist)
  1.  ;;   - describe psychosocial consequences of post-military trauma exposure(s)
  1.  ;;     (treatment received, disruption to work, adverse health consequences)
  1.  ;;
  1.  ;;     Post-Military Psychosocial Adjustment (refer to social-industrial survey
  1.  ;;     if completed)
  1.  ;;
  1.  ;;   - legal history (DWIs, arrests, time spent in jail)
  1.  ;;   - educational accomplishment
  1.  ;;   - employment history (describe periods of unemployment and reasons)
  1.  ;;   - marital and family relationships (including quality of relationships with
  1.  ;;     children)
  1.  ;;   - degree and quality of social relationships
  1.  ;;   - activities and leisure pursuits
  1.  ;;   - substance use and consequences of substance use
  1.  ;;   - significant medical disorders (resulting pain or disability; current
  1.  ;;     medications)
  1.  ;;   - treatment history for significant medical conditions, including 
  1.  ;;     hospitalizations
  1.  ;;   - history of inpatient and/or outpatient psychiatric care (dates and
  1.  ;;     conditions treated)
  1.  ;;   - history of assaultiveness
  1.  ;;   - history of suicide attempts
  1.  ;;   - 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.  ;;     relationships, recreation/leisure pursuits).
  1.  ;;TOF
  1.  ;;E.  Mental Status Examination
  1.  ;;
  1.  ;;    Conduct a 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.  ;;    - Impairment of thought process or communication
  1.  ;;    - Delusions, hallucinations and their persistence
  1.  ;;    - Eye Contact, interaction in session, and inappropriate behavior cited
  1.  ;;      with examples
  1.  ;;    - Suicidal or homicidal thoughts, ideations or plans or intent
  1.  ;;    - Ability to maintain minimal personal hygiene and other basic activities
  1.  ;;      of daily living
  1.  ;;    - Orientation to person, place, and time
  1.  ;;    - Memory loss, or impairment (both short and long-term)
  1.  ;;    - Obsessive or ritualistic behavior that interferes with routine activities
  1.  ;;    - Rate and flow of speech and note any irrelevant, illogical, or obscure
  1.  ;;      speech patterns and whether constant or intermittent
  1.  ;;    - 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.  ;;    - Depression, depressed mood or anxiety
  1.  ;;    - Impaired impulse control and its effect on motivation or mood
  1.  ;;    - Sleep impairment and describe extent it interferes with daytime
  1.  ;;      activities
  1.  ;;    - Other disorders or symptoms and the extent they interfere with activities