ptsd Got My Med Records...

[clw4514]

finally! i get to start my actual claim. looking over the records, i noticed at the time i reported the rape they even have documented in there that i was referred to MHC for ptsd. so, my question is....are mhc records separate from medical records? is that a specific request? if not, there is no record of me even being evaluated for it.

oh, and apparently them ordering me to AA was their explanation of alcohol rehab. i didnt go all the time and that is the reason i was put out. seriously? AA? come on now....that was just comical! it hurts none the less.

[Wings]

SOAP means Subjective, Objective, Assessment, Plan. It's an AF requirement for all medical record entries. I did hundreds as an AF med tech. Subjective: What is the patient's cheif complaint, what does s/he say (in her own words) is the problem? Objective: what does the med. technition see with her own eyes or medical instruments, how does the problem present itself? (bleeding, swelling, crying, etc.). Assessment: A Doctor or Nurse would make a formal Diagnosis here, whereas a an AF enlisted mental health tech. would do an brief asessment or triage (CAPS, concentration, attention, psychomotor, suicide/homocide ideation). Plan: next appointment, referral, sent home, etc.

Glad they recorded this visit!!! That's all the evidence you need for SC PTSD. ~Wings

Edited June 30, 2009 by Wings

[clw4514]

SOAP means Subjective, Objective, Assessment, Plan. It's an AF requirement for all medical record entries. I did hundreds as an AF med tech. Subjective: What is the patient's cheif complaint, what does s/he say (in her own words) is the problem? Objective: what does the med. technition see with her own eyes or medical instruments, how does the problem present itself? (bleeding, swelling, crying, etc.). Assessment: A Doctor or Nurse would make a formal Diagnosis here, whereas a an AF enlisted mental health tech. would do an brief asessment or triage (CAPS, concentration, attention, psychomotor, suicide/homocide ideation). Plan: next appointment, referral, sent home, etc.

Glad they recorded this visit!!! That's all the evidence you need for SC PTSD. ~Wings

seriously?? omg!!! i am so happy! will they still put me thru a c & p exam? i wonder what my rating will be. i know, im putting the cart before the horse but after 20 yrs, i need some relief. thx so much for all ur guidance, wings!! (((hugs)))

[Wings]

ASSESSMENT/DIAGNOSIS

I: post traumatic stress traits (v71.09); isolated ETOH [one time instance of alcohol] related incident (v71.09)

II: no dx (v71.09) NO PERSONALITY DISORDER DIAGNOSIS

PLAN: "encouraged Mental Health Clinic Follow-Up for PTSD mx [DNK MX?] squadron has responded PRP 2 (degree sign) [DNK PRP 2 degree sign] traumatic incident.

[clw4514]

ASSESSMENT/DIAGNOSIS

I: post traumatic stress traits (v71.09); isolated ETOH [one time instance of alcohol] related incident (v71.09)

II: no dx (v71.09) NO PERSONALITY DISORDER DIAGNOSIS

PLAN: "encouraged Mental Health Clinic Follow-Up for PTSD mx [DNK MX?] squadron has responded PRP 2 (degree sign) [DNK PRP 2 degree sign] traumatic incident.

im lost, wings....i dont know what the comments in blue mean.

[clw4514]

ASSESSMENT/DIAGNOSIS

I: post traumatic stress traits (v71.09); isolated ETOH [one time instance of alcohol] related incident (v71.09)

II: no dx (v71.09) NO PERSONALITY DISORDER DIAGNOSIS

PLAN: "encouraged Mental Health Clinic Follow-Up for PTSD mx [DNK MX?] squadron has responded PRP 2 (degree sign) [DNK PRP 2 degree sign] traumatic incident.

im a little slow today :( just figured out what ur saying there.....Mx is maintenance and PRP 2 (degree sign) - well, its written as 2 degrees w/ the little degree sign. since i dont have that stupid key on my computer....

[Wings]

im a little slow today :D just figured out what ur saying there.....Mx is maintenance and PRP 2 (degree sign) - well, its written as 2 degrees w/ the little degree sign. since i dont have that stupid key on my computer....

LOL! SO, what does "PRP" mean; is it a signature? Regardless, I don't think it's important. I had a service medical record notation of "anniversary reaction to a traumatic rape" --that helped my claim. Did you tell the C&P Examiner that document was in your C-File? It is in your C-File, right?! You'll be OK. ~Wings