Disability Examination Worksheets
Review Examination for Post-Traumatic Stress Disorder
Name: |
SSN: |
Date of Exam: |
C-number: |
Place of Exam: |
The following health care providers can perform review
examinations for PTSD.
a board-certified psychiatrist or board "eligible" psychiatrist;
a licensed doctorate-level psychologist;
a doctorate-level mental health provider under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist;
a psychiatry resident under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist;
a clinical or counseling psychologist completing a one year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist;
a licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, if they are clinically privileged to perform activities required for C&P mental disorder examinations, under close supervision of a board-certified or board eligible psychiatrist or doctorate-level psychologist.
. A. Review of Medical Records. B.
Medical History since last exam:
Comment on:
- Hospitalizations and outpatient care from the time between last
rating examination to the present, UNLESS the purpose of this examination is to
ESTABLISH service connection, then the complete medical history since discharge
from military service is required.
- significant medical disorders (resulting pain or disability; current medications)
- frequency, severity and duration of psychiatric symptoms.
- length of remissions from psychiatric symptoms, to include
capacity for adjustment during periods of remissions.
- treatments including statement on effectiveness and side effects
experienced.
- subjective Complaints: describe fully.
C. Psychosocial Adjustment since the last
exam
- legal history (DWIs, arrests, time spent in jail)
- educational accomplishments
- extent of time lost from work over the past 12 month period and
social impairment. If employed, identify current occupation and length of time
at this job. If unemployed, note in complaints whether veteran
contends it is due to the effects of a mental disorder. Further indicate
following DIAGNOSIS what factors, and objective findings support or
rebut that contention.
- marital and family relationships (including quality of
relationships with spouse and children)
- degree and quality of social relationships
- activities and leisure pursuits
- substance use and consequences of substance use
- history of violence / assaultiveness
- history of suicide attempts
- summary statement of current psychosocial functional status
(performance in employment or schooling, routine responsibilities of self care,
family role functioning, physical health, social/interpersonal relationships,
recreation/leisure pursuits)
D. Mental Status Examination
Conduct a brief mental status examination aimed at
screening for DSM-IV mental disorders. Describe and fully explain the
existence, frequency and extent of the following signs and symptoms, or any
others present, and relate how they interfere with employment and social
functioning:
- Impairment of thought process or communication.
- Delusions, hallucinations and their persistence.
- Eye contact, interaction in session, and inappropriate behavior
cited with examples.
- Suicidal or homicidal thoughts, ideations or plans or
intent.
- Ability to maintain minimal personal hygiene and other basic
activities of daily living.
- Orientation to person, place and time.
- Memory loss, or impairment (both short and long-term).
- Obsessive or ritualistic behavior which interferes with routine
activities and describe any found.
- Rate and flow of speech (note any irrelevant, illogical, or
obscure speech patterns and whether constant or intermittent.)
- Panic attacks noting the severity, duration, frequency and
effect on independent functioning and whether clinically observed or good
evidence of prior clinical or equivalent observation is shown.
- Depression, depressed mood or anxiety.
- Impaired impulse control and its effect on motivation or
mood.
- Sleep impairment and describe extent it interferes with daytime
activities.
- Other disorders or symptoms and the extent they interfere with
activities
E. Assessment of PTSD
- identify behavioral, cognitive, social, affective, or somatic symptoms veteran attributes to PTSD
- describe specific PTSD symptoms present (symptoms of trauma re-experiencing, avoidance/numbing, heightened physiological arousal, and associated features [e.g., disillusionment and demoralization])
- specify typical frequency and severity of symptoms
F. Psychometric Testing Results
- provide psychological testing if deemed necessary
- provide specific evaluation information required by the rating
board or on a BVA Remand.
- comment on validity of psychological test results
- provide scores for PTSD psychometric assessments
administered
- state whether PTSD psychometric measures are consistent or
inconsistent with a diagnosis of PTSD, based on normative data and established
"cutting scores" (cutting scores that are consistent with or supportive of a
PTSD diagnosis are as follows: PCL - not less than 50; Mississippi Scale not
less than 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or
2-7-8)
- state degree of severity of PTSD symptoms based on psychometric
data (mild, moderate, or severe)
- describe findings from psychological tests measuring problems
other than PTSD (MMPI, etc.)
G. Diagnosis:
- The Diagnosis must conform to DSM-IV and be supported by the
findings on the examination report.
- If there are multiple mental disorders discuss the relationship with PTSD.
- The evaluation is based on the effects of the signs and symptoms on occupational and social functioning.
NOTE: VA is prohibited by statute, 38 U.S.C. 1110,
from paying compensation for a disability that is a result of the veteran's own
ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
disability is secondary to or is caused or aggravated by a primary
service-connected disorder, the veteran may be entitled to compensation. See
Allen v.
Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). (If you do not have Microsoft Word software installed, you may download free viewer and reader software to view the case.)
Therefore, it is important
to determine the relationship, if any, between a service-connected disorder and
a disability resulting from the veteran's alcohol or drug abuse. Unless alcohol
or drug abuse is secondary to or is caused or aggravated by another mental
disorder, you should separate, to the extent possible, the effects of the
alcohol or drug abuse from the effects of the other mental disorder(s). If it
is not possible to separate the effects in such cases, please explain why.
H. Diagnostic Status
- Axis I disorders
- Axis II disorders
- Axis III disorders
- Axis IV (psychosocial and environmental problems)
- Axis V (GAF score: current)
I. Global Assessment of Functioning (GAF):
NOTE: The complete multi-axial format as specified by
DSM-IV may be required by BVA REMAND or specifically requested by the rating
specialist. If so, include the GAF score and note whether it refers to current
functioning. A BVA REMAND may also request, in addition to an overall GAF
score, that a separate GAF score be provided for each mental disorder present
when there are multiple Axis I or Axis II diagnoses and not all are service-
connected. If separate GAF scores can be given, an explanation and discussion
of the rationale is needed. If it is not possible, an explanation as to why not
is needed. (See the above note pertaining to alcohol or drug abuse.)
J. Capacity to Manage Financial Affairs: Mental
competency, for VA benefits purposes, refers only to the ability of the veteran
to manage VA benefit payments in his or her own best interest, and not to any
other subject. Mental incompetency, for VA benefits purposes, means that the
veteran, because of injury or disease, is not capable of managing benefit
payments in his or her best interest. In order to assist raters in making a
legal determination as to competency, please address the following:
What is the impact of injury or disease on the veteran's
ability to manage his or her financial affairs, including consideration of such
things as knowing the amount of his or her VA benefit payment, knowing the
amounts and types of bills owed monthly, and handling the payment prudently?
Does the veteran handle the money and pay the bills himself or
herself?
Based on your examination, do you believe that the veteran is
capable of managing his or her financial affairs? Please provide examples to
support your conclusion.
If you believe a Social Work Service assessment
is needed before you can give your opinion on the veteran's ability to manage
his or her financial affairs, please explain why.
K.
Other Opinion: Furnish any other specific opinion requested by the rating
board or BVA remand (i.e., furnish the complete rationale and citation of
medical texts or treatise supporting opinion, if medical literature review was
undertaken). If the requested opinion is medically not ascertainable on exam or
testing please state why. If the requested opinion can not be expressed without
resorting to speculation or making improbable assumptions say so, and explain
why. If the opinion asks " ... is it at least as likely as not ... ", fully
explain the clinical findings and rationale for the opinion.
L.
Integrated Summary and Conclusions
- Describe changes in psychosocial functional status and quality
of life since the last exam (performance in employment or schooling, routine
responsibilities of self care, family role functioning, physical health,
social/interpersonal relationships, recreation/leisure pursuits).
- Describe linkage between PTSD symptoms and aforementioned
changes in impairment in functional status and quality of life. Particularly
in cases where a veteran is unemployed, specific details about the effects of
PTSD and its symptoms on employment are especially important.
- If possible, describe extent to which disorders other than PTSD
(e.g., substance use disorders) are independently responsible for impairment in
psychosocial adjustment and quality of life. If this is not possible, explain
why (e.g., substance use had onset after PTSD and clearly is a means of coping
with PTSD symptoms).
- If possible, state prognosis for improvement of psychiatric
condition and impairments in functional status.
- Comment on whether veteran is capable of managing his or her
financial affairs.
M.
Effects of PTSD on Occupational and Social Functioning
Evaluation of PTSD is based on its effects on occupational and social functioning. Select the appropriate assessment of the veteran from the choices below:
- Total occupational and social impairment due to PTSD signs and symptoms.
Provide examples and pertinent symptoms, including those already reported.
OR
- PTSD signs and symptoms result in deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood.
Provide examples and pertinent symptoms, including those already reported for each affected area.
OR
- There is reduced reliability and productivity due to PTSD signs and symptoms.
Provide examples and pertinent symptoms, including those already reported.
OR
- There is occasional decrease in work efficiency or there are intermittent periods of inability to perform occupational tasks due to signs and symptoms, but generally satisfactory functioning (routine behavior, self-care, and conversation normal).
Provide examples and pertinent symptoms, including those already reported.
OR
- There are PTSD signs and symptoms that are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.
Provide examples and pertinent symptoms, including those already reported.
OR
- PTSD symptoms require continuous medication
OR
- Select all that apply:
- PTSD symptoms are not severe enough to require continuous medication.
- PTSD symptoms are not severe enough to interfere with occupational and social functioning.
Include your name; your credentials, i.e., a board certified
psychiatrist, a licensed psychologist, a psychiatry resident or a psychology
intern, LCSW, or NP and circumstances under which you performed the
examination, if applicable, i.e., under the close supervision of an attending
psychiatrist or psychologist; include name of supervising psychiatrist or
psychologist.
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Reviewed/Updated Date: December 15, 2008 |
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