©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
DVBCWRO1 ;ALB/ESW RESPIRATORY WKS TEXT - 1 ; 6 OCT 2000
;;2.7;AMIE;**34**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;; Comment on:
;;
;; 1. Productive cough, sputum, hemoptysis, and/or anorexia.
;; 2. Extent of dyspnea on exertion.
;; 3. If veteran is asthmatic, report frequency of attacks and
;; baseline functional status between attacks.
;; 4. Treatment (type, frequency and duration including a need for
;; oxygen), response, side effects.
;; 5. Describe frequency and duration of any periods of incapacitation
;; (defined as requiring bed rest and treatment by a physician).
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following as appropriate to the condition
;; being examined and fully describe current findings:
;;
;; 1. Presence of cor pulmonale, RVH, or pulmonary hypertension.
;; 2. Weight loss or gain.
;; 3. For restrictive disease, describe condition underlying restrictive
;; disease, e.g., kyphoscoliosis, pectus excavatum, etc., unless already
;; of record.
;;
;;D. Diagnostic and Clinical Tests:
;;Provide:
;;
;;1. PULMONARY FUNCTION TESTS (unless carried out within past six months and
;; the report is either in the claims folder or will be attached to this
;; examination report, e.g., PFT's were in VAMC records at your facility).
;; Spirometric pulmonary function testing should include FVC,FEV-1, and
;; the FEV-1/FVC ratio. Both pre- and post-bronchodilatation test results should
;; be reported. If post-bronchodilatation testing is not conducted
;; in a particular case, please provide an explanation of why not. A DLCO may
;; or may not be done routinely as part of pulmonary function testing
;; at a particular facility. If there is a disparity between the results of
;; different tests, please indicate which tests are more likely to accurately
;; reflect the severity of the condition.
;;TOF
;; DLCO note:
;; If the DLCO was not done as a routine part of pulmonary function testing,
;; the examiner should use his or her judgment, based on the specific
;; condition (e.g., whether it is obstructive, interstitial, etc.) and
;; other available information about the condition, as to whether a DLCO test
;; is needed, since it is not useful in all situations. If it may provide
;; useful information about the severity of the condition, it should be
;; requested and reviewed before the examination report is submitted.
;; If the examiner determines that the DLCO test is not needed, a statement
;; as to why not (e.g., there are decreased lung volumes that would not yield
;; valid test results) should be included in the report. Such a statement
;; could avoid a remand from BVA when the test is not done. However,
;; in the case of a BVA remand in which the DLCO is requested, the DLCO MUST
;; be done unless there is a medical contraindication.
;;
;;2. Chest X-ray (if no recent results available).
;;3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END