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Routine: DVBCWTB3

DVBCWTB3.m

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  1. DVBCWTB3 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;   11. Endocrine dysfunction.  If evidence of endocrine dysfunction is
  1.  ;;       identified or suspected, select and follow the additional appropriate
  1.  ;;       examination protocol for the type of endocrine disorder identified.
  1.  ;;   12. Autonomic dysfunction.  Report any symptoms of autonomic dysfunction,
  1.  ;;       such as heat intolerance, excess or decreased sweating, etc.
  1.  ;;   13. Other abnormal physical findings.
  1.  ;;   14. Assessment of cognitive impairment and other residuals of TBI not
  1.  ;;       otherwise classified:
  1.  ;;    
  1.  ;;Instruction:  Select the specific choice for each of the following items
  1.  ;;(after completion of neuropsychological testing, if done).  State on the
  1.  ;;examination report which of the choices best describes each of the items.
  1.  ;;Do not report by using the number of the item or the letter of the description.
  1.  ;;Report the title of the item:  "Memory, attention, concentration, executive
  1.  ;;functions," etc., and then state the correct description, e.g., "There is
  1.  ;;objective evidence on testing of mild impairment of memory (and/or attention,
  1.  ;;and/or concentration, and/or executive functions) resulting in mild functional
  1.  ;;impairment."
  1.  ;;
  1.  ;;   I. Memory, attention, concentration, executive functions
  1.  ;;      a. No complaints of impairment of memory, attention, concentration or
  1.  ;;      executive functions.
  1.  ;;      b. A complaint of mild memory loss (such as having difficulty following
  1.  ;;      a conversation, recalling recent conversations, remembering names of new
  1.  ;;      acquaintances, or finding words, or often misplacing items), attention,
  1.  ;;      concentration, or executive functions, but without objective evidence
  1.  ;;      on testing.
  1.  ;;      c. Objective evidence on testing of mild impairment of memory,
  1.  ;;      attention, concentration, or executive functions resulting in mild
  1.  ;;      functional impairment.
  1.  ;;      d. Objective evidence on testing of moderate impairment of memory,
  1.  ;;      attention, concentration, or executive functions resulting in moderate
  1.  ;;      functional impairment.
  1.  ;;      e. Objective evidence on testing of severe impairment of memory,
  1.  ;;      attention, concentration, or executive functions resulting in severe
  1.  ;;      functional impairment.
  1.  ;;
  1.  ;;  II. Judgment
  1.  ;;      a. Normal.
  1.  ;;      b. Mildly impaired judgment.  For complex or unfamiliar decisions,
  1.  ;;      occasionally unable to identify, understand, and weigh the alternatives,
  1.  ;;      understand the consequences of choices, and make a reasonable decision.
  1.  ;;      c. Moderately impaired judgment.  For complex or unfamiliar decisions,
  1.  ;;      usually unable to identify, understand, and weigh the alternatives,
  1.  ;;      understand the consequences of choices, and make a reasonable decision,
  1.  ;;      although has little difficulty with simple decisions.
  1.  ;;      d. Moderately severely impaired judgment.  For even routine and familiar
  1.  ;;      decisions, occasionally unable to identify, understand, and weigh the
  1.  ;;      alternatives, understand the consequences of choices, and make a 
  1.  ;;      reasonable decision.
  1.  ;;      e. Severely impaired judgment.  For even routine and familiar decisions,
  1.  ;;      usually unable to identify, understand, and weigh the alternatives,
  1.  ;;      understand the consequences of choices, and make a reasonable decision.
  1.  ;;      For example, unable to determine appropriate clothing for current
  1.  ;;      weather conditions or judge when to avoid dangerous situations or
  1.  ;;      activities.
  1.  ;;
  1.  ;; III. Social Interaction
  1.  ;;      a. Social interaction is routinely appropriate.
  1.  ;;      b. Social interaction is occasionally inappropriate.
  1.  ;;      c. Social interaction is frequently inappropriate.
  1.  ;;      d. Social interaction is inappropriate most or all of the time.
  1.  ;;
  1.  ;;  IV. Orientation
  1.  ;;      a. Always oriented to person, time, place, and situation.
  1.  ;;      b. Occasionally disoriented to one of the four aspects (person, time,
  1.  ;;      place, situation) of orientation.
  1.  ;;      c. Occasionally disoriented to two of the four aspects (person, time,
  1.  ;;      place, situation) of orientation or often disoriented to one aspect of
  1.  ;;      orientation.
  1.  ;;      d. Often disoriented to two or more of the four aspects (person, time,
  1.  ;;      place, situation) of orientation.
  1.  ;;      e. Consistently disoriented to two or more of the four aspects (person,
  1.  ;;      time, place, situation) of orientation.
  1.  ;;
  1.  ;;   V. Motor activity (with intact motor and sensory system)
  1.  ;;      a. Motor activity normal.
  1.  ;;      b. Motor activity normal most of the time, but mildly slowed at times
  1.  ;;      due to apraxia (inability to perform previously learned motor activities,
  1.  ;;      despite normal motor function).
  1.  ;;      c. Motor activity mildly decreased or with moderate slowing due to
  1.  ;;      apraxia.
  1.  ;;      d. Motor activity moderately decreased due to apraxia.
  1.  ;;      e. Motor activity severely decreased due to apraxia.
  1.  ;;
  1.  ;;  VI. Visual spatial orientation
  1.  ;;      a. Normal.
  1.  ;;      b. Mildly impaired.  Occasionally gets lost in unfamiliar surroundings,
  1.  ;;      has difficulty reading maps or following directions.  Is able to use
  1.  ;;      assistive devices such as GPS (global positioning system).
  1.  ;;      c. Moderately impaired.  Usually gets lost in unfamiliar surroundings,
  1.  ;;      has difficulty reading maps, following directions, and judging distance.
  1.  ;;      Has difficulty using assistive devices such as GPS (global positioning
  1.  ;;      system).
  1.  ;;      d. Moderately severely impaired.  Gets lost even in familiar
  1.  ;;      surroundings, unable to use assistive devices such as GPS (global
  1.  ;;      positioning system).
  1.  ;;      e. Severely impaired.  May be unable to touch or name own body parts
  1.  ;;      when asked by the examiner, identify the relative position in space of
  1.  ;;      two different objects, or find the way from one room to another in a 
  1.  ;;      familiar environment.
  1.  ;;
  1.  ;; VII. Subjective symptoms
  1.  ;;      a. Subjective symptoms that do not interfere with work; instrumental
  1.  ;;      activities of daily living; or work, family, or other close
  1.  ;;      relationships.  Examples are:  mild or occasional headaches, mild
  1.  ;;      anxiety.
  1.  ;;      b. Three or more subjective symptoms that mildly interfere with work;
  1.  ;;      instrumental activities of daily living; or work, family, or other
  1.  ;;      close relationships.  Examples of findings that might be seen at this
  1.  ;;      level of impairment are:  intermittent dizziness, daily mild to moderate
  1.  ;;      headaches, tinnitus, frequent insomnia, hypersensitivity to sound,
  1.  ;;      hypersensitivity to light.
  1.  ;;      c. Three or more subjective symptoms that moderately interfere with
  1.  ;;      work; instrumental activities of daily living; or work, family, or other
  1.  ;;      close relationships.  Examples of findings that might be seen at this
  1.  ;;      level of impairment are:  marked fatigability, blurred or double vision,
  1.  ;;      headaches requiring rest periods during most days.
  1.  ;;
  1.  ;;VIII. Neurobehavioral effects
  1.  ;;      a. One or more neurobehavioral effects that do not interfere with
  1.  ;;      workplace interaction or social interaction.  Examples of
  1.  ;;      neurobehavioral effects are:  irritability, impulsivity,
  1.  ;;      unpredictability, lack of motivation, verbal aggression, physical
  1.  ;;      aggression, belligerence, apathy, lack of empathy, moodiness, lack of
  1.  ;;      cooperation, inflexibility, and impaired awareness of disability.  Any
  1.  ;;      of these effects may range from slight to severe, although verbal and
  1.  ;;      physical aggression are likely to have a more serious impact on
  1.  ;;      workplace interaction and social interaction than some of the other
  1.  ;;      effects.
  1.  ;;      b. One or more neurobehavioral effects that occasionally interfere with
  1.  ;;      workplace interaction, social interaction, or both but do not preclude
  1.  ;;      them.
  1.  ;;      c. One or more neurobehavioral effects that frequently interfere with
  1.  ;;      workplace interaction, social interaction, or both but do not preclude
  1.  ;;      them.
  1.  ;;      d. One or more neurobehavioral effects that interfere with or preclude
  1.  ;;      workplace interaction, social interaction, or both on most days or that
  1.  ;;      occasionally require supervision for safety of self or others.
  1.  ;;
  1.  ;;  IX. Communication
  1.  ;;      a. Able to communicate by spoken and written language (expressive
  1.  ;;      communication), and to comprehend spoken and written language.
  1.  ;;      b. Comprehension or expression, or both, of either spoken language or
  1.  ;;      written language is only occasionally impaired.  Can communicate complex
  1.  ;;      ideas.
  1.  ;;      c. Inability to communicate either by spoken language, written language,
  1.  ;;      or both, more than occasionally but less than half of the time, or to
  1.  ;;      comprehend spoken language, written language, or both, more than
  1.  ;;      occasionally but less than half of the time.  Can generally communicate
  1.  ;;      complex ideas.
  1.  ;;      d. Inability to communicate either by spoken language, written language,
  1.  ;;      or both, at least half of the time but not all of the time, or to
  1.  ;;      comprehend spoken language, written language, or both, at least half of
  1.  ;;      the time but not all of the time.  May rely on gestures or other
  1.  ;;      alternative modes of communication.  Able to communicate basic needs.
  1.  ;;      e. Complete inability to communicate either by spoken language, written
  1.  ;;      language, or both, or to comprehend spoken language, written language,
  1.  ;;      or both.  Unable to communicate basic needs.
  1.  ;;