169 lines
7.4 KiB
Mathematica
169 lines
7.4 KiB
Mathematica
DVBCWMO1 ;ALB/JFP MENTAL DISORDERS (EXCEPT INITIAL PTSD AND EATING DISORDERS) WKS TEXT - 1 ; 13 FEB 1998
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;;2.7;AMIE;**16**;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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;;
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;; Comment on:
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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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;;
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;; b. Medical and occupational history from the time between
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;; last rating examination and the present, UNLESS the
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;; purpose of this examination is to ESTABLISH service
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;; connection, then the complete medical history since
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;; discharge from military service is required.
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;;
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;; 2. Present Medical, Occupational, and Social History - over the
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;; past one year.
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;;
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;; a. Frequency, severity, and duration of psychiatric symptoms.
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;;
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;; b. Length of remissions, to include capacity for adjustment
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;; during periods of remissions.
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;;
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;; c. Extent of time lost from work over the past 12 month
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;; period and social impairment. If employed, identify
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;; current occupation and length of time at this job. If
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;; unemployed, note in complaints whether veteran contends it
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;; is due to the effects of a mental disorder. Further
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;; indicate following DIAGNOSIS what factors, and objective
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;; findings support or rebut that contention.
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;;
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;; d. Treatments including statement on effectiveness and side
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;; effects 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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;;TOF
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;;C. Examination (Objective Findings):
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;;
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;; Address each of the following and fully describe:
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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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;;
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;; 2. Additionally, to allow evaluation by the rating specialist,
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;; describe and fully explain the existence, frequency, and
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;; extent of the following signs and symptoms, or any others
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;; present, and relate how they interfere with employment and
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;; social functioning:
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;;
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;; a. Impairment of thought process or communication.
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;;
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;; b. Delusions, hallucinations and their persistence.
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;;
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;; c. Inappropriate behavior cited with examples.
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;;
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;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
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;;
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;; e. Ability to maintain personal hygiene and other basic
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;; activities of daily living.
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;;
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;; f. Orientation to person, place, and time.
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;;
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;; g. Memory loss or impairment (both short and/or long term).
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;;
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;; h. Obsessive or ritualistic behavior which interferes with
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;; routine activities (describe with examples).
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;;
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;; i. Rate and flow of speech and note irrelevant, illogical, or
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;; obscure speech patterns and whether constant or intermittent.
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;;
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;; j. Panic attacks noting the severity, duration, frequency and
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;; effect on independent functioning and whether clinically
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;; observed or good evidence of prior clinical or equivalent
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;; observation.
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;;
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;; k. Depression, depressed mood, or anxiety.
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;;
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;; l. Impaired impulse control and its effect on motivation or mood.
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;;
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;; m. Sleep impairment and describe extent it interferes with
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;; daytime activities.
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;;
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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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;;TOF
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;;D. Diagnostic Tests:
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;;
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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
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;; considered in arriving at the diagnosis.
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;; 3. Provide any specific evaluation information required by the
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;; rating board or on BVA Remand (in claims folder).
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;;
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;; a. COMPETENCY: State whether the veteran is capable of
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;; managing his/her benefit payments in the individual's own
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;; best interests (a physical disability which prevents the
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;; veteran from attending to financial matters in person is
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;; not a proper basis for a finding of incompetency unless
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;; the veteran is, by reason of that disability, incapable of
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;; directing someone else in handling the individual's
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;; 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
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;; supporting opinion, if medical literature review was under-
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;; taken. If the requested opinion is medically not ascertainable
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;; on exam or testing, please indicate why. If the requested
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;; opinion can not be expressed without resorting to
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;; speculation or making improbable assumptions say so, and
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;; explain why. If the opinion asks "...is it at least as
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;; likely as not..?", fully explain the clinical findings and
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;; rationale for the opinion.
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;;
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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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;;
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;;TOF
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;;E. Diagnosis:
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;;
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;; Provide:
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;; 1. The Diagnosis must conform to DSM-IV and be supported by the
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;; findings on the examination report.
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;; 2. If the diagnosis is changed, explain fully whether the new
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;; diagnosis represents a progression of the prior diagnosis or
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;; development of a new and separate condition.
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;; 3. If there are multiple mental disorders, delineate to the
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;; extent possible the symptoms associated with each and a
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;; discussion of relationship.
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;; 4. Evaluation is based on the effects of the signs and symptoms
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;; on occupational and social functioning.
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;;
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;;NOTE: VA is prohibited by statute from paying compensation for a
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;;disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE,
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;;whether based on direct service connection, secondary service connection,
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;;or aggravation by a service-connected condition. Therefore, when
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;;alcohol or drug abuse accompanies or is associated with another mental
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;;disorder, separate, to the extent possible, the effects of the alcohol
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;;or drug abuse from the effects of the other mental disorder(s). If it
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;;is not possible to separate the effects, explain why.
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;;
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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
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;;be required by BVA REMAND or specifically requested by the rating
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;;specialist. If so, include the GAF score and note whether it
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;;refers to current functioning over the past year, etc.
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;;
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;;If multiple Axis or Axis II diagnoses exist, attempt, to the extent
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;;possible, to provide a GAF score for the service connected conditions
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;;alone as well as a separate overall GAF score based on all mental
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;;disorders present and explain and discuss the rationale. (See the
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;;above note pertaining to alcohol or drug abuse, effects of which cannot
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;;be used to assess the effects of a service-connected condition.) If
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;;unable to separate symptomatology, explain why.
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;;
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;;
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;;Signature: Date:
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;;END
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