DVBCWPG2 ;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 ;
;;TOF
;;E. Assessment of PTSD
;;
;; - identify behavioral, cognitive, social, affective, or somatic symptoms
;; veteran attributes to PTSD
;; - describe specific PTSD symptoms present (symptoms of trauma
;; re-experiencing, avoidance/numbing, heightened physiological arousal,
;; and associated features [e.g., disillusionment and demoralization])
;; - specify typical frequency, and severity of symptoms
;;
;;F. Psychometric Testing Results
;;
;; - provide psychological testing if deemed necessary
;; - provide specific evaluation information required by the rating board or
;; on a BVA Remand
;; - comment on validity of psychological test results
;; - provide scores for PTSD psychometric assessments administered
;; - state whether PTSD psychometric measures are consistent or inconsistent
;; with a diagnosis of PTSD, based on normative data and established
;; "cutting scores" (cutting scores that are consistent with or supportive
;; of a PTSD diagnosis are as follows: PCL - not less than 50;
;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
;; greater than 28; MMPI code type: 2-8 or 2-7-8)
;; - state degree of severity of PTSD symptoms based on psychometric data
;; (mild, moderate, or severe)
;; - describe findings from psychological tests measuring other than
;; PTSD (MMPI, etc.)
;;
;;G. Diagnosis:
;;
;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
;; on the examination report.
;; 2. If there are multiple mental disorders, discuss the relationship with
;; PTSD.
;; 3. The evaluation is based on the effects of the signs and symptoms on
;; occupational and social functioning.
;;
;; NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying
;; compensation for a disability that is a result of the veteran's own
;; ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
;; disability is secondary to or is caused or aggravated by a primary
;; service-connected disorder, the veteran may be entitled to compensation.
;; See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore,
;; it is important to determine the relationship, if any, between a
;; service-connected disorder and a disability resulting from the veteran's
;; alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or
;; is caused or aggravated by another mental disorder, you should separate,
;; to the extent possible, the effects of the alcohol or drug abuse from
;; the effects of the other mental disorder(s). If it is not possible
;; to separate the effects in such cases, please explain why.
;;TOF
;;H. Diagnostic Status
;;
;; - Axis I disorders
;; - Axis II disorders
;; - Axis III disorders
;; - Axis IV (psychosocial and environmental problems)
;; - Axis V (GAF score - current)
;;
;;I. Global Assessment of Functioning (GAF):
;;
;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
;; by BVA REMAND or specifically requested by the rating specialist. If so,
;; include the GAF score and note whether it refers to current functioning.
;; A BVA REMAND may also request, in addition to an overall GAF score,
;; that a separate GAF score be provided for each mental disorder present when
;; there are multiple Axis I or Axis II diagnoses and not all are service-
;; connected. If separate GAF scores can be given, an explanation and
;; discussion of the rationale is needed. If it is not possible, an
;; explanation as to why not is needed. (See the above note pertaining to
;; alcohol or drug abuse.)
;;
;;J. Capacity to Manage Financial Affairs
;;
;; Mental competency, for VA benefits purposes, refers only to the ability
;; of the veteran to manage VA benefit payments in his or her own best
;; interest, and not to any other subject. Mental incompetency,
;; for VA benefits purposes, means that the veteran, because of injury
;; or disease, is not capable of managing benefit payments in his or her
;; best interest. In order to assist raters in making a legal determination
;; as to competency, please address the following:
;;
;; What is the impact of injury or disease on the veteran's ability
;; to manage his or her financial affairs, including consideration
;; of such things as knowing the amount of his or her VA benefit
;; payment, knowing the amounts and types of bills owed monthly,
;; and handling the payment prudently? Does the veteran handle
;; his or her money and pay the bills?
;;
;; Based on your examination, do you believe that the veteran is
;; capable of managing his or her financial affairs?
;; Please provide examples to support your conclusion.
;;
;; If you believe a Social Work Service assessment is needed before
;; you can give your opinion on the veteran's ability to manage his
;; or her financial affairs, please explain why.
;;
;;K. Other Opinion:
;;
;; Furnish any other specific opinion requested by the rating
;; board or BVA remand (i.e., furnish the complete rationale and citation of
;;TOF
;; medical texts or treatise supporting opinion, if medical literature review
;; was undertaken). If the requested opinion is medically not ascertainable
;; on exam or testing please state why. If the requested opinion can not be
;; expressed without resorting to speculation or making improbable assumptions
;; say so, and explain why. If the opinion asks "... is it at least as likely
;; as not..", fully explain the clinical findings and rationale for the
;; opinion.
;;
;;L. Integrated Summary and Conclusions
;;
;; 1. Describe changes in psychosocial functional status and quality of life
;; since the last exam (performance in employment or schooling, routine
;; responsibilities of self care, family role functioning, physical health,
;; social/interpersonal relationships, recreation/leisure pursuits)
;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
;; impairment in functional status and quality of life.
;; Particularly in cases where a veteran is unemployed, specific details
;; about the effects of PTSD and its symptoms on employment are especially
;; important.
;; 3. If possible, describe extent to which disorders other than PTSD
;; (e.g., substance use disorders) are independently responsible for
;; impairment in psychosocial adjustment and quality of life. If this is
;; not possible, explain why (e.g., substance use had onset after PTSD
;; and clearly is a means of coping with PTSD symptoms).
;; 4. If possible, state prognosis for improvement of psychiatric condition
;; and impairments in functional status.
;; 5. Comment on whether the veteran is capable of managing his/her
;; benefit payments in his/her own best interest.
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWPG2 7547 printed Dec 13, 2024@01:53:31 Page 2
DVBCWPG2 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ; 05/18/2006 12:00pm
+1 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
+2 ;Per VHA Directive 10-92-142, this routine should not be modified
+3 ;
TXT ;
+1 ;;TOF
+2 ;;E. Assessment of PTSD
+3 ;;
+4 ;; - identify behavioral, cognitive, social, affective, or somatic symptoms
+5 ;; veteran attributes to PTSD
+6 ;; - describe specific PTSD symptoms present (symptoms of trauma
+7 ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
+8 ;; and associated features [e.g., disillusionment and demoralization])
+9 ;; - specify typical frequency, and severity of symptoms
+10 ;;
+11 ;;F. Psychometric Testing Results
+12 ;;
+13 ;; - provide psychological testing if deemed necessary
+14 ;; - provide specific evaluation information required by the rating board or
+15 ;; on a BVA Remand
+16 ;; - comment on validity of psychological test results
+17 ;; - provide scores for PTSD psychometric assessments administered
+18 ;; - state whether PTSD psychometric measures are consistent or inconsistent
+19 ;; with a diagnosis of PTSD, based on normative data and established
+20 ;; "cutting scores" (cutting scores that are consistent with or supportive
+21 ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
+22 ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
+23 ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
+24 ;; - state degree of severity of PTSD symptoms based on psychometric data
+25 ;; (mild, moderate, or severe)
+26 ;; - describe findings from psychological tests measuring other than
+27 ;; PTSD (MMPI, etc.)
+28 ;;
+29 ;;G. Diagnosis:
+30 ;;
+31 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
+32 ;; on the examination report.
+33 ;; 2. If there are multiple mental disorders, discuss the relationship with
+34 ;; PTSD.
+35 ;; 3. The evaluation is based on the effects of the signs and symptoms on
+36 ;; occupational and social functioning.
+37 ;;
+38 ;; NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying
+39 ;; compensation for a disability that is a result of the veteran's own
+40 ;; ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
+41 ;; disability is secondary to or is caused or aggravated by a primary
+42 ;; service-connected disorder, the veteran may be entitled to compensation.
+43 ;; See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore,
+44 ;; it is important to determine the relationship, if any, between a
+45 ;; service-connected disorder and a disability resulting from the veteran's
+46 ;; alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or
+47 ;; is caused or aggravated by another mental disorder, you should separate,
+48 ;; to the extent possible, the effects of the alcohol or drug abuse from
+49 ;; the effects of the other mental disorder(s). If it is not possible
+50 ;; to separate the effects in such cases, please explain why.
+51 ;;TOF
+52 ;;H. Diagnostic Status
+53 ;;
+54 ;; - Axis I disorders
+55 ;; - Axis II disorders
+56 ;; - Axis III disorders
+57 ;; - Axis IV (psychosocial and environmental problems)
+58 ;; - Axis V (GAF score - current)
+59 ;;
+60 ;;I. Global Assessment of Functioning (GAF):
+61 ;;
+62 ;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
+63 ;; by BVA REMAND or specifically requested by the rating specialist. If so,
+64 ;; include the GAF score and note whether it refers to current functioning.
+65 ;; A BVA REMAND may also request, in addition to an overall GAF score,
+66 ;; that a separate GAF score be provided for each mental disorder present when
+67 ;; there are multiple Axis I or Axis II diagnoses and not all are service-
+68 ;; connected. If separate GAF scores can be given, an explanation and
+69 ;; discussion of the rationale is needed. If it is not possible, an
+70 ;; explanation as to why not is needed. (See the above note pertaining to
+71 ;; alcohol or drug abuse.)
+72 ;;
+73 ;;J. Capacity to Manage Financial Affairs
+74 ;;
+75 ;; Mental competency, for VA benefits purposes, refers only to the ability
+76 ;; of the veteran to manage VA benefit payments in his or her own best
+77 ;; interest, and not to any other subject. Mental incompetency,
+78 ;; for VA benefits purposes, means that the veteran, because of injury
+79 ;; or disease, is not capable of managing benefit payments in his or her
+80 ;; best interest. In order to assist raters in making a legal determination
+81 ;; as to competency, please address the following:
+82 ;;
+83 ;; What is the impact of injury or disease on the veteran's ability
+84 ;; to manage his or her financial affairs, including consideration
+85 ;; of such things as knowing the amount of his or her VA benefit
+86 ;; payment, knowing the amounts and types of bills owed monthly,
+87 ;; and handling the payment prudently? Does the veteran handle
+88 ;; his or her money and pay the bills?
+89 ;;
+90 ;; Based on your examination, do you believe that the veteran is
+91 ;; capable of managing his or her financial affairs?
+92 ;; Please provide examples to support your conclusion.
+93 ;;
+94 ;; If you believe a Social Work Service assessment is needed before
+95 ;; you can give your opinion on the veteran's ability to manage his
+96 ;; or her financial affairs, please explain why.
+97 ;;
+98 ;;K. Other Opinion:
+99 ;;
+100 ;; Furnish any other specific opinion requested by the rating
+101 ;; board or BVA remand (i.e., furnish the complete rationale and citation of
+102 ;;TOF
+103 ;; medical texts or treatise supporting opinion, if medical literature review
+104 ;; was undertaken). If the requested opinion is medically not ascertainable
+105 ;; on exam or testing please state why. If the requested opinion can not be
+106 ;; expressed without resorting to speculation or making improbable assumptions
+107 ;; say so, and explain why. If the opinion asks "... is it at least as likely
+108 ;; as not..", fully explain the clinical findings and rationale for the
+109 ;; opinion.
+110 ;;
+111 ;;L. Integrated Summary and Conclusions
+112 ;;
+113 ;; 1. Describe changes in psychosocial functional status and quality of life
+114 ;; since the last exam (performance in employment or schooling, routine
+115 ;; responsibilities of self care, family role functioning, physical health,
+116 ;; social/interpersonal relationships, recreation/leisure pursuits)
+117 ;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
+118 ;; impairment in functional status and quality of life.
+119 ;; Particularly in cases where a veteran is unemployed, specific details
+120 ;; about the effects of PTSD and its symptoms on employment are especially
+121 ;; important.
+122 ;; 3. If possible, describe extent to which disorders other than PTSD
+123 ;; (e.g., substance use disorders) are independently responsible for
+124 ;; impairment in psychosocial adjustment and quality of life. If this is
+125 ;; not possible, explain why (e.g., substance use had onset after PTSD
+126 ;; and clearly is a means of coping with PTSD symptoms).
+127 ;; 4. If possible, state prognosis for improvement of psychiatric condition
+128 ;; and impairments in functional status.
+129 ;; 5. Comment on whether the veteran is capable of managing his/her
+130 ;; benefit payments in his/her own best interest.