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

[brokensoldier244th]

Well, that answers that. I emailed the C&P examiner, politely, at his office practice, figuring that if the VA assigned him to me for a C&P and I dished on myself for over an hour that that must constitute some form of patient/doctor relationship.

Apparently not. My request to have him clarify his findings to reflect whether or not my depression was or was not service connected was replied to with: "You need to contact the RegionalOffice to direct information that pertains to your claims. This is not myVA Account and is my personal office. Have a nice day."

Well, 1, you aren't a VA employee, so you may not HAVE a VA address, 2. I don't think I can contact the VA about an insufficient report until Im (possibly) denied anyway and Id really like to not have to appeal this, 3. you have a publicly listed fax, phone number at your practice that is freely available on the Web via a simple google search. I didnt think I was out of line, since I spent almost 2 hours in your 'office' for my C&P as a 'patient'. but hey, what the hell ever.

CAS

[Hoppy]

If it were me and the claim is denied I would contact the director of the hospital and tell them that you had a C&P exam and the examiner did not address the nexus issue one way or the other. Tell the director you feel that the exam was inadaquate and it should have addressed the nexus issue with full supporting logic justifying any determination. In the absence of the nexus the issue the exam is useless. Please investigate this examiner and provide me with an adaquate exam.

According to several SO's who I asked the question as to how to report C&P examiners I was told the C&P examiners work for the director of the hospital and to file complaints with the director of the hospital. A veteran who posted on hadit a couple years ago said this worked for him and he got a new C&P that was scheduled by the hospital.

Edited August 30, 2011 by Hoppy

[brokensoldier244th]

I will follow up with that route. The 2nd response I received from the Dr, after he told me that I need to contact the appropriate person and I said that he was the appropriate person since he wrote the report, was

" The regional office is theappropriate channel not me. The federal govt will deem fit whether my exam isinsufficient. Then they will contact me. This is the exact chain of command"

So, I guess I get to talk to the VAMC. Thank you, Hoppy.

If it were me and the claim is denied I would contact the director of the hospital and tell them that you had a C&P exam and the examiner did not address the nexus issue one way or the other. Tell the director you feel that the exam was inadaquate and it should have addressed the nexus issue with full supporting logic justifying any determination. In the absence of the nexus the issue the exam is useless. Please investigate this examiner and provide me with an adaquate exam.

According to several SO's who I asked the question as to how to report C&P examiners I was told the C&P examiners work for the director of the hospital and to file complaints with the director of the hospital. A veteran who posted on hadit a couple years ago said this worked for him and he got a new C&P that was scheduled by the hospital.

Edited August 30, 2011 by brokensoldier244th

[Hoppy]

The regional office and the hospital are actually two different entities. The RO can request an exam. However, in previous cases where it was obvious to me the C&P was bogus I was told to complain to the director of the hospital. You can also complain to the RO. However, the veteran who complained to the director of the hospital got a quicker response and new exam. The doctors have some discretion over their actions. I have obtained C&P like exams from VA clinicians in cases where the RO refused to even schedule a C&P. The exams I obtained for veterans were cited by DRO's as sufficient evidence to award the claim.

[brokensoldier244th]

Should I wait to complain, since my claim is in decision, or should I wait and pursue it after?

CAS

The regional office and the hospital are actually two different entities. The RO can request an exam. However, in previous cases where it was obvious to me the C&P was bogus I was told to complain to the director of the hospital. You can also complain to the RO. However, the veteran who complained to the director of the hospital got a quicker response and new exam. The doctors have some discretion over their actions. I have obtained C&P like exams from VA clinicians in cases where the RO refused to even schedule a C&P. The exams I obtained for veterans were cited by DRO's as sufficient evidence to award the claim.

[Hoppy]

I mentioned in aprevious post "if you get denied go to the director of the hospital."The same would apply here for the RO. There is the possibility that your statementto your treating psychologist and her reports will over ride the C&P. ThisC&P examiner won’t even talk to you and he is being adversarial. As of now the C&P report was notspecifically developed to present evidence against the claim. If you complain to the RO before the decision,there is a possibility they will send the exam back to him and he will come upwith the BS logic supporting a less likely than not connected. I have rebuttedthese BS opinions by obtaining reports from other clinicians. It makes for more work and sometimes IMO’sthat are costly. If I feel an examineris being adversarial I totally take another route and get another doctor towrite reports. It is the old be careful what you ask for thing.