Mh C&p In, Some Questions About Symptoms Noted Vs. Progress Notes

[brokensoldier244th]

I got my MH C&P notes back today, and as I peruse them I don't see too much that is glaringly off until I get to the "Symptoms" section in Section II, Clinical notes. Under the list of symptoms, only Depressed Mood is marked [X]. Nothing about disturbances of motivation or mood, disturbances of sleep, mild memory loss-things that are in my treatment notes with my Psychologist. Under the "Occupational Social Impairment" section he checked: "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation".

Tossing and turning, mind-mapping to keep thing straight, and my lack of motivation for social settings is noted in the write up under "current mental health", though. I just hope that stuff typed out in block gets read, too, and not just the things that are 'X'd off.

It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23) when my normal treatment notes from early April to present designate it as recurrent. How does a rater take that and run with it?

Is it normal for there to only have 1 thing marked in that entire symptoms section, even though the instructions state to check any and all symptoms related to the diagnosis? The rating isn't just based off of the checklist, is it? They will look at my psych notes,etc as well, where these things are noted? I thought the C&P was to take that into account in their overall write up, summarizing it, if you will, but maybe not. Is there going to be any weirdness with having only a single GAF when my clinician uses SOAP style notes with no GAF scores? (thus, no pattern)

My Axis(s) were listed as:

Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)

Diagnosis 2 (none)

Axis II Nothing listed

Axis III Medical diagnois-C&P records

Axis IV

Service related lumbar spine and sciatic nerve

GAF score 58

"There is no history of mental health hospitalization. The veteran was started on Sertraline by the physician initially for PME and then over time he started taking that daily for his mood, 1/2 tab daily"

"The veteran is married, 4 children. The veterans wife is employed as asst. manager of a movie theater. The veteran noted that often times they watch DVR or rental movies for family activity. The veteran noted that usually after the new movies have been out a few weeks they are more likely to do to movies when there will be less of a crowd."The veteran noted that his children are involved in [activities] and that he is involved, his wife does the majority of those activities."

"The veteran noted that Sertraline has calming effect upon his emotions and thought process. The veteran noted that he has been trying to work on physical prowess by exercising but that Physical Therapy said he was working too hard and in a manner that would not be conducive to reduction in pain. The veteran has avoided narcotic pain medication as he does not want to further dull his faculties. the veteran does not that there are times where he does not have an appetite and forgets to eat. The veterans energy level has been low to poor. The veteran noted that he will "mind map" to keep his clientele straight. The veteran has difficulty getting comfortable at night. The veteran tosses and turns repeatedly during the night. The veteran noted that he tends to be regimented and structured so as to try to contain the depressive symptomology.

The veteran noted that hsi sex drive is "not really...we cuddle, we dont' have sex......I take drugs for it, but then I don't 'want to'....". The veteran does not feel hopeless-he says that is why he sees his psychologist. the veteran does have some time he feels helpless. The veteran knows that his back pain "is going to be a lifetime thing. I get sick of it...i get tired of it hurting...i get tired of people asking why I don't spend time with them or do things with them... because there are days i can't get off the couch."

The veteran has friends "and we do things sometimes, my close friends understand most of the time. Acquaintances feel like I am a buzz kill". The veteran is not suicidal nor homicidal. Th vetera's mood is depressed daily nearly every day or all day, he describes difficult concentrating at home and at work."

Edited August 29, 2011 by brokensoldier244th

[Hoppy]

Why didn't I think of that? I did try this with A VA staff clinician and got thrown out of his office. I tried it with another VA staff clinician who made a diagnosis of a less severe condition than what the treating reports stated. He typed up an ammendment while I waited. What would you do if the guy says "Oh dude I am so sorry. Why of course it is related to your back. I will type up an ammendment while you wait".

[brokensoldier244th]

Is that sarcasm? :-) Sorry, my sarcasometer is pegged this week.

As for whether I would trust an addendum right there, probably not-id feel like I was pressuring or threatening them, I guess.

Why didn't I think of that? I did try this with A VA staff clinician and got thrown out of his office. I tried it with another VA staff clinician who made a diagnosis of a less severe condition than what the treating reports stated. He typed up an ammendment while I waited. What would you do if the guy says "Oh dude I am so sorry. Why of course it is related to your back. I will type up an ammendment while you wait".

[Hoppy]

It's more like irony than sarcasm. A person struggles to figure out what went wrong with the exam and how to resovle the problem and in the end the solution was simple. This is more an explanation of irony than a statement as to what I think will happen. Approaching doctors for an addendum is a coin flip. I have told veterans to do it and it worked and I have gone to appointments with them and it has worked. Unfortunately, it only works about 50% of the time.

The last veteran who I worked with that pulled this off told his psychiatrist that he had reported a mis diagnosis for a year and a half. He pointed out that he had a different diagnosis which was determined by psychometric testing and his psychologist had been reporting the right diagnosis the entire year and a half. The C&P examiner based a denial on the wrong diagnosis the psychiatrist had been reporting. The psychiatrist admitted the error and wrote an addendum changing the diagnosis. This resulted in the C&P going into the trash can. The doctors do not re write the entire report. They write an addendum. Sometimes the addendums get lost. You need to submit them with a statement in support of the claim and make sure they appear on the evidence listing.

To win my angioedema claim I had to get pushy. The raters were making up false evidence against the claim and ignoring slam dunk evidence in favor of the claim.

[brokensoldier244th]

we'll see what he says, and go from there. At least I tried, and those who dare.......

CAS

It's more like irony than sarcasm. A person struggles to figure out what went wrong with the exam and how to resovle the problem and in the end the solution was simple. This is more an explanation of irony than a statement as to what I think will happen. Approaching doctors for an addendum is a coin flip. I have told veterans to do it and it worked and I have gone to appointments with them and it has worked. Unfortunately, it only works about 50% of the time.

The last veteran who I worked with that pulled this off told his psychiatrist that he had reported a mis diagnosis for a year and a half. He pointed out that he had a different diagnosis which was determined by psychometric testing and his psychologist had been reporting the right diagnosis the entire year and a half. The C&P examiner based a denial on the wrong diagnosis the psychiatrist had been reporting. The psychiatrist admitted the error and wrote an addendum changing the diagnosis. This resulted in the C&P going into the trash can. The doctors do not re write the entire report. They write an addendum. Sometimes the addendums get lost. You need to submit them with a statement in support of the claim and make sure they appear on the evidence listing.

To win my angioedema claim I had to get pushy. The raters were making up false evidence against the claim and ignoring slam dunk evidence in favor of the claim.

[Hoppy]

CAS

A veteran posted a report he got from a VA treating psychiatrist under another topic. The topic was "Berta and others". I copied and pasted his axis I diagnosis. This is what your psychologist can do for you. It involves making an accurate current diagnosis. Why she is balking at this is most likely a policy local to her department or hospital administrator. 2008-71 does not say a doctor does not need to make assessments that result in the most accurate diagnosis. The single episode can change to recurrent in your case because that is what the psychologist has been diagnosing you with.

I also saw a VA Psychiatrist – First Visit. He said

Axis I: Major Depressive Disorder, single episode, mild to moderate, likely related to

his Ulcerated Colitis.

Axis II: Deferred

Axis III: Ulcerated Colitis, hypertension, hyperglycemia

Axis IV: Moderate to severe

Axis V: GAF 60

[brokensoldier244th]

Im in decision phase as of today, so we'll see what happens.

My Axis(s) were listed as:

Axis I Diagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)

Diagnosis 2 (none)

Axis II Nothing listed

Axis III Medical diagnois-C&P records

Axis IV

Service related lumbar spine and sciatic nerve

GAF score 58

CAS

A veteran posted a report he got from a VA treating psychiatrist under another topic. The topic was "Berta and others". I copied and pasted his axis I diagnosis. This is what your psychologist can do for you. It involves making an accurate current diagnosis. Why she is balking at this is most likely a policy local to her department or hospital administrator. 2008-71 does not say a doctor does not need to make assessments that result in the most accurate diagnosis. The single episode can change to recurrent in your case because that is what the psychologist has been diagnosing you with.

I also saw a VA Psychiatrist – First Visit. He said

Axis I: Major Depressive Disorder, single episode, mild to moderate, likely related to

his Ulcerated Colitis.

Axis II: Deferred

Axis III: Ulcerated Colitis, hypertension, hyperglycemia

Axis IV: Moderate to severe

Axis V: GAF 60