Generic Form "at Least As Likely"

[cannoncocker]

I can't seem to search and find or find my old Neurology generic form that allows the clinician to along with their own notes/findings cann check of the appropriate box that they find applies to:

At least as likely as not Service connected

not at least as likely as not

so on

Have received and reviewed Service Medical Records.

Does anyone have a link to that form for a psychiatric IMO. The SOC would be funny but they used it to push me to the back of the line so I figured an IMO has moved things along before.

There is a visible scar on my body in a visible place which would have one purpose which they denied existed, then I showed that to the VA Clinicians and they just couldn't believe what they were reading. I know they wanted to laugh but couldn't really go with the gut reaction. The Contract VA Psychiatric Exam did reach the conclusion they were wanting. So a NOD or DRO with an IMO seems like my best next move, but I need a generic form to make it easier and be sure all the bases are covered.

Thanks for any links.

Edited August 30, 2010 by cannoncocker

[cannoncocker]

Forget it . Found the form.

[GuaymasJim]

CC,

Please post the location of the form for other members or up load a copy. Many have similar situations and could use the form.

Thanks,

[allan]

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 accomplishmentsextent 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 relationshipsactivities and leisure pursuitssubstance use and consequences of substance use history of violence / assaultivenesshistory of suicide attemptssummary 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 activitiesE. 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 ) specify typical frequency and severity of symptoms F. Psychometric Testing Results provide psychological testing if deemed necessaryprovide specific evaluation information required by the rating board or on a BVA Remand. comment on validity of psychological test resultsprovide scores for PTSD psychometric assessments administeredstate 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 disordersAxis II disordersAxis III disordersAxis 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. ORPTSD 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. ORThere is reduced reliability and productivity due to PTSD signs and symptoms.

Provide examples and pertinent symptoms, including those already reported. ORThere 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. ORThere 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. ORPTSD symptoms require continuous medication ORSelect 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.



Signiture..................................................................Date.........................................



Link to VA Examination Worksheet for PTSD: http://www.vba.va.go...ms/disexm56.htm

Link to VA Examination Worksheet for Mental Disorders (Except initial PTSD and Eating Disorders) http://www.vba.va.go...ms/disexm37.htm

Edited August 30, 2010 by allan