VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWAH1.m

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DVBCWAH1 ;ALB/CMM A&A OR HOUSEBOUND WKS TEXT - 1 ; 7 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;NARRATAIVE: Once the existence of at least a single disability rated
;;at 100% has been established, additional benefits may be payable if
;;the veteran requires:
;;
;; 1. The regular assistance of another person in attending to the
;; ordinary hazards of daily living.
;; 2. Assistance of another in protecting himself or herself from
;; the ordinary hazards of his or her daily environment, and/or
;; 3. If the veteran is restricted to his or her home or the immediate
;; vicinity thereof, including the ward or immediate clinical
;; area, if hospitalized.
;;
;;
;;A. Review Of Medical Records:
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Indicate whether or not the veteran requires an attendant in
;; reporting for this exam, and if so, identify the nurse or attendant
;; and the mode of travel employed.
;;
;;
;; 2. Indicate whether or not the veteran is hospitalized, and if so,
;; state where and the date of admission.
;;
;;
;; 3. Indicate whether or not the veteran is permanently bedridden.
;;
;;
;; 4. Indicate whether of not the veteran's best corrected vision is
;; 5/200 or worse in both eyes.
;;
;;
;; 5. State whether the veteran is capable of managing benefit patments
;; in his or her own best interests without restriction. (A physical
;; disability which prevents the veteran from attending to financial
;; matters in person is not a proper basis for a finding of incompetency
;; unless he or she is, by reason of that disability, incapable or
;; directing someone else in handling financial affairs.)
;;
;;
;; 6. Capacity to protect oneself from the hazards/dangers of daily
;; environment:
;;
;; a. Describe briefly any pathological processes involving other
;; body parts and systems, including the effects of advancing
;; age, such as dizziness, bowel/bladder incontinence, loss of
;; memory, poor balance affecting ability to ambulate, performing
;; self-care, or travel beyond the premises of the home (or the
;; ward or clinical area if hospitalized).
;;
;;
;; b. Describe where the veteran goes and what he or she does
;; during a typical day.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Comment on:
;; 1. General Appearance.
;;
;;
;; 2. Height and weight (including maximum and minimum weight for past year.
;;
;;
;; 3. Build and posture.
;;
;;
;; 4. State of nutrition.
;;
;;
;; 5. Gait.
;;
;;
;; 6. Temperature, pulse, respiration.
;;
;;
;; 7. Blood Pressure.
;;
;;
;; 8. Upper extremities (reporting each upper extremity separately):
;;
;; a. Describe functional restrictions with reference to
;; strength and coordination and ability for self-feeding,
;; fastening clothing, bathing, shaving, and toileting.
;;
;;
;; b. If amputated, indicate level of amputation (or length of
;; stump and whether or not use of a prosthesis is feasible).
;;
;; 9. Lower extremities (reporting each lower extremity separately):
;;
;; a. Describe functional restrictions with reference to extent
;; of limitation of motion, muscle atrophy, contractures,
;; weakness, lack of coordination, or other interference.
;;
;;
;; b. Indicate any deficits of weight bearing, balance, and propulsion.
;;
;;
;; c. If amputated, indicate level of amputation (or length of
;; stump and whether use of a prosthesis is feasible).
;;
;;
;; 10. Spine, trunk and neck:
;; Describe any limitation of motion or deformity of lumbar,
;; thoracic, and cervical spine.
;;
;;
;; 11. Note if deformity of thoracic spine interferes with breathing.
;;
;;
;; 12. Ambulation:
;;
;; a. Indicate whether the veteran is able to walk without the
;; assistance of another person and give the maximum distance.
;;
;;
;; b. Indicate any mechanical aid used or recommended by the examiner.
;;
;;
;; c. Indicate the frequency, and under what circumstances, the
;; veteran is able to leave the home or immediate premises.
;;
;; 13. Except as to amputations and other anatomical losses, indicate
;; if any restrictions noted in the examination are permanent.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. No specific diagnostic testing required unless required to evaluate
;; the veteran as required above.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END