©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWPW1 ;ALB/CMM PULMONARY TB AND MYCO. DIS. WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Activity of pulmonary tuberculosis or other mycobacterial disease.
;;
;;
;; 2. Date of inactivity if it is not active.
;;
;;
;; 3. Identity of organism (if possible).
;;
;;
;;C. Physical examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Extent of structural damage to lungs.
;;
;;
;; 2. If patient was hospitalized for 6 months or more, what is the
;; condition at the end of hospitalization?
;;
;;
;; 3. If patient was hospitalized for 12 months or more, what is the
;; condition at the end of hospitalization?
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Provide:
;; Pulmonary Function Tests, if indicated. When the results of
;; pre-bronchodilator pulmonary function tests are NORMAL, post-
;; bronchodilator studies are not required for VA evaluation purposes.
;; IN ALL OTHER CASES, post-bronchodilator studies shuld be conducted
;; unless contraindicated (because of allergy to medication, etc.) or
;; if the veteran was on bronchodilators before the test and had taken
;; his or her medication within a few hours of the study. An examiner
;; who determines that a post-bronchodilator study should not be
;; performed should provide an explanation of why not. If there is
;; a disparity between the results of different pulmonary function
;; tests (FEV-1, FVC, etc.), the examiner should indicate which test
;; result is the best indicator of the veteran's level of pulmonary
;; functioning.
;;
;;
;;E. Diagnosis:
;;
;; In reactivated cases, is this reactivation of the old disease or a
;; separate and distinct new infection.
;;
;;
;;
;;ADDITIONAL NOTE TO THE PHYSICIAN:
;;In all claims, if the disease is inactive and if the inactivity was
;;confirmed at a non-VA facility, obtain the name and mailing address of
;;the facility from the veteran so that the Regional Office may request
;;the report.
;;
;;
;;Signature: Date:
;;END