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Routine: DVBCWPG1

DVBCWPG1.m

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DVBCWPG1 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ;05/18/2006 12:00pm

 ;;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 review examinations for PTSD:

 ;;

 ;;     - a board certified or board "eligible" psychiatrist;

 ;;     - a licensed doctorate-level psychologist;

 ;;     - a doctorate-level mental health provider under 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;

 ;;     - a clinical or counseling psychologist completing a one year internship

 ;;       or residency (for the purposes of a doctorate-level degree) under

 ;;       close supervision of a board certified or board eligible psychiatrist

 ;;       or licensed doctorate-level psychologist;

 ;;     - a licensed clinical social worker (LCSW), a nurse practitioner,

 ;;       a clinical nurse specialist, or a physician assistant, if they are

 ;;       clinically privileged to perform activities required for C&P mental

 ;;       disorder examinations, under close supervision of a board certified

 ;;       or board eligible psychiatrist or doctorate-level psychologist.

 ;;

 ;;A.  Review of Medical Records

 ;;

 ;;B.  Medical History since last exam:

 ;;

 ;;     Comment 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.  Significant medical disorders (resulting pain or disability; current

 ;;         medications).

 ;;     3.  Frequency, severity and duration of psychiatric symptoms.

 ;;     4.  Length of remissions from psychiatric symptoms, to include capacity

 ;;         for adjustment during periods of remissions.

 ;;     5.  Treatments including statement on effectiveness and side effects

 ;;         experienced.

 ;;     6.  Subjective Complaints: Describe fully.

 ;;

 ;;C.  Psychosocial Adjustment since the last exam

 ;;

 ;;    - legal history (DWIs, arrests, time spent in jail)

 ;;    - educational accomplishment

 ;;TOF

 ;;    - extent of time lost 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

 ;;    - substance use and consequences of substance us

 ;;      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)

 ;;

 ;;D.  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