Section D. Examination Reports

[allan]

Section D. Examination Reports

Overview

In this Section This section contains the topic “Reviewing Department of Veterans Affairs (VA) Examination Reports.”

18. Reviewing Department of Veterans Affairs (VA) Examination Reports

Introduction This topic contains information about determining the adequacy of Department of Veterans Affairs (VA) examination reports, including

• who must sign examination reports

• ensuring examiners are qualified

• who must sign VA medical center (VAMC) reports

• qualification requirements of examiners for

 initial mental disorder examinations, and

 review or increased evaluation mental disorder examinations

• requirements for examination reports

• returning examination reports as insufficient for rating purposes

• returning examination reports for clarification

• evaluating disability diagnoses

• resolving inconsistencies

• handling unusual cases, and

• accepting a fee-based examiner’s report.

Change Date December 29, 2007

a. Who Must Sign Examination Reports All original examination reports must be signed by a physician, unless the examination was performed by a

• clinical or counseling psychologist

• dentist

• audiologist, or

• optometrist.

Notes:

• Reports of physical examinations conducted by qualified medical examiners other than physicians, such as nurse practitioners or physician’s assistants, are acceptable if the reports are reviewed and signed by a physician.

• Examination reports transmitted by Compensation and Pension Record Interchange (CAPRI) (Department of Veterans Affairs (VA) medical center examinations) or EXAMTRAK (contract examinations) without signatures are acceptable since signed copies are maintained by the Veterans Health Administration (VHA) or contract examining facility.

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b. Ensuring Examiners Are Qualified VA medical facilities (or the medical examination contractor) are responsible for ensuring that examiners are adequately qualified.

Veterans Service Center (VSC) employees are not expected to routinely review the credentials of clinical personnel to determine the acceptability of their reports.

Note: The signature block of the examination report should contain the examiner’s credentials.

c. Who Must Sign VAMC Reports If an unsigned or improperly signed examination report is received, the report must be returned as incomplete for rating purposes before undertaking any adjudicative action.

The physician in charge of the case must sign the original hospital summary from a VA medical center (VAMC).

Note: The Veterans Service Center Manager (VSCM) should contact the Registrar of the medical facility concerned to prevent the frequent submission of unsigned summaries.

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d. Qualification Requirements of Examiners – Initial Mental Disorder Examinations Mental health professionals with the following credentials are qualified to perform initial compensation and pension (C&P) mental disorder examinations:

• board-certified or board-eligible psychiatrists

• licensed doctorate-level psychologists, and

• the following other mental health professionals, under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist:

 doctorate-level mental health providers

 psychiatry residents, and

 clinical or counseling psychologists completing a one-year internship or residency.

Note: “Close supervision” means that the supervising psychiatrist or psychologist met with the veteran and conferred with the examining mental health professional in providing the diagnosis and the final assessment. The supervising psychiatrist or psychologist must co-sign the examination report.

e. Qualification Requirements of Examiners – Review or Increased Evaluation Mental Disorder Examinations Mental health professionals with the following credentials are qualified to perform C&P mental disorder review examinations or examinations in claims for increased evaluations of service-connected (SC) mental disorders:

• mental health professionals qualified to perform initial mental disorder examinations per M21-1MR, Part III, Subpart iv, 3.D.18.d, and

• other mental health professional under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist, including

 licensed clinical social workers

 nurse practitioners

 clinical nurse specialists, and

 physician assistants.

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f. Requirements for Examination Reports Any VA examination report submitted to the rating activity, including VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, must be as complete as possible.

The examination report must include

• an up-to-date, brief, medical and industrial history from the date of discharge or last examination

• a record of subjective complaints

• a complete description of objective findings, stated in concrete terms

• a diagnosis of all described conditions

• answers to any question specifically requested in the examination request

• opinions specifically requested in the exam request

• a diagnosis or notation that a chronic disease or disability was ruled out for each disability, complaint, or symptom listed on the examination request, and

• the clinical findings required by the rating schedule for the evaluation of the specific disability being claimed. (For example, if a joint is being examined, the range of motion in degrees should be noted as part of the examination. If a cardiovascular condition is being examined, the metabolic equivalent expanded before fatigue, chest pain, and so on, result should be expressed.)

Important: A VA examination report that does not meet all the above requirements is not sufficient.

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g. Returning Examination Reports as Insufficient for Rating Purposes Return an examination report as insufficient for rating purposes to the clinic or health care facility Director with a statement describing the deficiencies in the report, if any of the following is true:

• the examination report is unsigned, unless transmitted via

 AMIE/CAPRI, or

 VERIS

• the examination report did not address all disabilities for which an examination was requested

• the same disability is diagnosed differently by different examiners

• conclusions or findings have been expressed in ambiguous or equivocal terms, and/or

• the examiner has not discussed the impact of musculoskeletal pain on the functional loss of an affected joint.

Important: Avoid using language that can be construed as adversarial when returning reports for clarification. Use the term “insufficient for rating purposes” rather than “inadequate examination.”

Notes:

• Use AMIE/CAPRI to return an insufficient report to the examining facility if the examination was requested through AMIE/CAPRI.

• Request the VSC Contract Examination Coordinator to return an insufficient report to the contractor if the examination was requested through VERIS.

Reference: For more information on descriptions of pain affecting functional loss, see Floyd v. Brown, 9 Vet. App. 88 (1996).

h. Returning Examination Reports for Clarification Return an examination report for clarification if

• an examination report shows a change in the diagnosis or etiology for a disability previously recognized as service-connected, and

• the medical examiner has not made the required certification that the previous diagnosis or attributed etiology upon which service connection was based was in error.

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i. Evaluating Disability Diagnoses The precise cause of a disability is often difficult to determine. It is important that

• the same disability is not covered by more than one diagnosis, and

• a definite and unambiguous diagnosis is made for each complaint or symptom having a medical cause.

j. Resolving Inconsistencies Resolve any inconsistency and duplication between the findings of various specialists and the general examination by a conference among the examiners.

k. Handling Unusual Cases If necessary, the VSCM should discuss unusual cases with health care officials to ensure proper understanding of the issue or issues at hand.

l. Accepting a Fee-Based Examiner’s Report There is no prohibition against acceptance of a VA examination for rating purposes by a fee-based medical examiner that has previously submitted a statement on the claimant’s behalf.

Edited August 18, 2009 by allan