136 lines
7.2 KiB
Mathematica
136 lines
7.2 KiB
Mathematica
DVBCWPG2 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ; 05/18/2006 12:00pm
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;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
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;Per VHA Directive 10-92-142, this routine should not be modified
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;
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TXT ;
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;;TOF
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;;E. Assessment of PTSD
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;;
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;; - identify behavioral, cognitive, social, affective, or somatic symptoms
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;; veteran attributes to PTSD
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;; - describe specific PTSD symptoms present (symptoms of trauma
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;; re-experiencing, avoidance/numbing, heightened physiological arousal,
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;; and associated features [e.g., disillusionment and demoralization])
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;; - specify typical frequency, and severity of symptoms
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;;
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;;F. Psychometric Testing Results
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;;
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;; - provide psychological testing if deemed necessary
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;; - provide specific evaluation information required by the rating board or
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;; on a BVA Remand
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;; - comment on validity of psychological test results
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;; - provide scores for PTSD psychometric assessments administered
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;; - state whether PTSD psychometric measures are consistent or inconsistent
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;; with a diagnosis of PTSD, based on normative data and established
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;; "cutting scores" (cutting scores that are consistent with or supportive
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;; of a PTSD diagnosis are as follows: PCL - not less than 50;
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;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
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;; greater than 28; MMPI code type: 2-8 or 2-7-8)
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;; - state degree of severity of PTSD symptoms based on psychometric data
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;; (mild, moderate, or severe)
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;; - describe findings from psychological tests measuring other than
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;; PTSD (MMPI, etc.)
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;;
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;;G. Diagnosis:
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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 there are multiple mental disorders, discuss the relationship with
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;; PTSD.
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;; 3. The 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, 38 U.S.C. 1110, from paying
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;; compensation for a disability that is a result of the veteran's own
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;; ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
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;; disability is secondary to or is caused or aggravated by a primary
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;; service-connected disorder, the veteran may be entitled to compensation.
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;; See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore,
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;; it is important to determine the relationship, if any, between a
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;; service-connected disorder and a disability resulting from the veteran's
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;; alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or
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;; is caused or aggravated by another mental disorder, you should separate,
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;; to the extent possible, the effects of the alcohol or drug abuse from
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;; the effects of the other mental disorder(s). If it is not possible
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;; to separate the effects in such cases, please explain why.
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;;TOF
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;;H. Diagnostic Status
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;;
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;; - Axis I disorders
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;; - Axis II disorders
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;; - Axis III disorders
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;; - Axis IV (psychosocial and environmental problems)
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;; - Axis V (GAF score - current)
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;;
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;;I. 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,
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;; that a separate GAF score be provided for each mental disorder present when
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;; there are multiple Axis I or Axis II diagnoses and not all are service-
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;; connected. If separate GAF scores can be given, an explanation and
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;; discussion of the rationale is needed. If it is not possible, an
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;; explanation as to why not is needed. (See the above note pertaining to
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;; alcohol or drug abuse.)
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;;
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;;J. Capacity to Manage Financial Affairs
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;;
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;; Mental competency, for VA benefits purposes, refers only to the ability
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;; of the veteran to manage VA benefit payments in his or her own best
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;; interest, and not to any other subject. Mental incompetency,
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;; for VA benefits purposes, means that the veteran, because of injury
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;; or disease, is not capable of managing benefit payments in his or her
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;; best interest. In order to assist raters in making a legal determination
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;; as to competency, please address the following:
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;;
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;; What is the impact of injury or disease on the veteran's ability
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;; to manage his or her financial affairs, including consideration
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;; of such things as knowing the amount of his or her VA benefit
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;; payment, knowing the amounts and types of bills owed monthly,
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;; and handling the payment prudently? Does the veteran handle
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;; his or her money and pay the bills?
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;;
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;; Based on your examination, do you believe that the veteran is
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;; capable of managing his or her financial affairs?
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;; Please provide examples to support your conclusion.
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;;
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;; If you believe a Social Work Service assessment is needed before
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;; you can give your opinion on the veteran's ability to manage his
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;; or her financial affairs, please explain why.
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;;
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;;K. Other Opinion:
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;;
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;; Furnish any other specific opinion requested by the rating
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;; board or BVA remand (i.e., furnish the complete rationale and citation of
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;;TOF
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;; medical texts or treatise supporting opinion, if medical literature review
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;; was undertaken). If the requested opinion is medically not ascertainable
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;; on exam or testing please state why. If the requested opinion can not be
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;; expressed without resorting to speculation or making improbable assumptions
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;; say so, and explain why. If the opinion asks "... is it at least as likely
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;; as not..", fully explain the clinical findings and rationale for the
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;; opinion.
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;;
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;;L. Integrated Summary and Conclusions
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;;
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;; 1. Describe changes in psychosocial functional status and quality of life
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;; since the last exam (performance in employment or schooling, routine
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;; responsibilities of self care, family role functioning, physical health,
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;; social/interpersonal relationships, recreation/leisure pursuits)
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;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
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;; impairment in functional status and quality of life.
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;; Particularly in cases where a veteran is unemployed, specific details
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;; about the effects of PTSD and its symptoms on employment are especially
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;; important.
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;; 3. If possible, describe extent to which disorders other than PTSD
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;; (e.g., substance use disorders) are independently responsible for
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;; impairment in psychosocial adjustment and quality of life. If this is
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;; not possible, explain why (e.g., substance use had onset after PTSD
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;; and clearly is a means of coping with PTSD symptoms).
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;; 4. If possible, state prognosis for improvement of psychiatric condition
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;; and impairments in functional status.
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;; 5. Comment on whether the veteran is capable of managing his/her
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;; benefit payments in his/her own best interest.
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