135 lines
7.2 KiB
Mathematica
135 lines
7.2 KiB
Mathematica
DVBCWME1 ;ALB/ESW MENTAL DISORDERS (except PTSD AND Eating Disorders) WKS TEXT - 1 ; 6 OCT 2000
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;;2.7;AMIE;**34**;Apr 10, 1995
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;
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;
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;B. Medical History (Subjective Complaints):
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;; Comment on:
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;;
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;; 1. Past Medical History:
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;;
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;; a. Previous hospitalizations and outpatient care.
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;; b. Medical and occupational history from the time between last rating
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;; examination and the present, UNLESS the purpose of this examination
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;; is to ESTABLISH service connection, then the complete medical history
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;; since discharge from military service is required.
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;;
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;; 2. Present Medical, Occupational, and Social History -
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;; over the past one year.
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;;
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;; a. Frequency, severity, and duration of psychiatric symptoms.
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;; b. Length of remissions, to include capacity for adjustment during
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;; periods of remissions.
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;; c. Extent of time lost from work over the past 12 month period and
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;; social impairment. If employed, identify current occupation and
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;; length of time at this job. If unemployed, note in Complaints whether
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;; veteran contends it is due to the effects of a mental disorder.
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;; Further indicate following DIAGNOSIS what factors, and objective
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;; findings support or rebut that contention.
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;; d. Treatments including statement on effectiveness and side effects
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;; experienced.
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;;
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;; 3. Subjective Complaints:
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;;
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;; a. Describe fully.
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;;
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;;C. Examination (Objective Findings):
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;; Address each of the following and fully describe:
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;;
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;; 1. Mental status exam to confirm or establish diagnosis in
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;; accordance with DSM-IV.
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;; 2. Additionally, to allow evaluation by the rating specialist, describe
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;; and fully explain the existence, frequency, and extent of the following
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;; signs and symptoms, or any others present, and relate how they interfere
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;; with employment and social functioning:
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;; a. Impairment of thought process or communication.
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;; b. Delusions, hallucinations and their persistence.
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;; c. Inappropriate behavior cited with examples.
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;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
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;; e. Ability to maintain minimal personal hygiene and other basic
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;; activities of daily living.
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;; f. Orientation to person, place and time.
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;; g. Memory loss or impairment (both short and/or long term).
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;; h. Obsessive or ritualistic behavior which interferes with routine
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;; activities (describe with examples).
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;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
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;; speech patterns and whether constant or intermittent.
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;; j. Panic attacks noting the severity, duration, frequency and effect
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;; on independent functioning and whether clinically observed or good
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;; evidence of prior clinical or equivalent observation.
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;; k. Depression, depressed mood, or anxiety.
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;; l. Impaired impulse control and its effect on motivation or mood.
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;; m. Sleep impairment and describe extent it interferes with daytime
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;; activities.
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;; n. Other symptoms and the extent to which they interfere with
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;; activities.
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;;
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;;D. Diagnostic Tests:
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;; 1. Provide psychological testing if deemed necessary.
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;; 2. If testing is requested, the results must be reported and considered in
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;; arriving at the diagnosis.
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;; 3. Provide any specific evaluation information required by the rating board
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;; or on BVA Remand (in claims folder).
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;;
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;; a. COMPETENCY: State whether the veteran is capable of managing
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;; his/her benefit payments in the individual's own best interests
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;; (a physical disability which prevents the veteran from attending
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;; to financial matters in person is not a proper basis for a finding
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;; of incompetency unless the veteran is, by reason of that
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;; disability, incapable of directing someone else in handling
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;; the individual's financial affairs).
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;;
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;; b. OTHER OPINION: Furnish any other specific opinion requested
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;; by the rating board or BVA Remand furnishing the complete
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;; rationale and citation of medical texts or treatise supporting
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;; opinion, if medical literature review was undertaken.
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;; If the requested opinion is medically not ascertainable on exam
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;; or testing, please indicate WHY. If the requested opinion can not
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;; be expressed without resorting to speculation or making improbable
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;; assumptions say so, and explain why. If the opinion asks "...is it
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;; at least as likely as not..?", fully explain the clinical findings
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;; and rationale for the opinion.
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;; 4. Include results of all diagnostic and clinical tests conducted
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;; in the examination report.
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;;TOF
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;;E. Diagnosis:
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;; Provide:
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;;
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;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
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;; on the examination report.
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;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
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;; represents a progression of the prior diagnosis or development of a new
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;; and separate condition.
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;; 3. If there are multiple mental disorders, delineate to the extent possible
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;; the symptoms associated with each and a discussion of relationship.
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;; 4. Evaluation is based on the effects of the signs and symptoms on
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;; occupational and social functioning.
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;;
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;;NOTE: VA is prohibited by statute from paying compensation for a disability
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;;that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on
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;;direct service connection, secondary service connection, or aggravation by
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;;a service-connected condition. Therefore, when alcohol or drug abuse
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;;accompanies or is associated with another mental disorder, separate, to
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;;the extent possible, the effects of the alcohol or drug abuse from the effects
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;;of the other mental disorder(s). If it is not possible to separate the effects,
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;;explain why.
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;;
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;;F. Global Assessment of Functioning (GAF):
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;;
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;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
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;;by BVA REMAND or specifically requested by the rating specialist. If so,
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;;include the GAF score and note whether it refers to current functioning.
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;;A BVA REMAND may also request , in addition to an overall GAF score, that a
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;;separate GAF score be provided for each mental disorder present when there are
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;;multiple Axis I or Axis II diagnoses and not all are service-connected.
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;;If separate GAF scores can be given, an explanation and discussion of
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;;the rationale is needed. If it is not possible, an explanation as to why not is
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;;needed. (See the above note pertaining to alcohol or drug abuse, the effects of
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;; which cannot be used to assess the effects of a service-connected condition.)
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;;
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;;
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;;Signature: Date:
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;;END
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