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ptsd Reopen Claim Please Help Hoorah
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Question
cperez
Posted:
22 minutes agoProblems/Conditions
Department of Veterans Affairs Description of the information included in this section
Problems/Conditions
This section contains a list of Problems/Conditions known to VA for the patient. It includes both active and inactive
problems/conditions. The data comes from all VA treatment facilities. Data is available 3 calendar days after it has been entered by a
VA provider.
Problems - Count (11) Status Problem Code Date of Onset Provider Source
Back Pain ACTIVE 724.5 -- --
Allergic rhinitis ACTIVE 477.9 -- --
HTN ACTIVE 401.9 -- --
Schizophrenia ACTIVE 295.90 -- --
Headaches ACTIVE 784.0 -- --
Dizziness ACTIVE 780.4 -- --
Asthma, unspecified type, with status
asthmaticus
ACTIVE 493.91 -- --
Schizoaffective disorder ACTIVE 295.70 -- -
Posttraumatic stress disorder ACTIVE 309.81 -- --
SUICIDE/HOMICIDE ASSESSMENT:
Are you having thoughts today about killing yourself? ( x) No ( ) Yes
Do you have a plan to kill yourself ( ) No ( ) Yes Describe the plan
Do you have means to carry out the plan? ( x) No ( ) Yes
Risk Level ( ) No Risk ( x) Low ( ) Moderate ( ) High
RISK FACTORS IDENTIFIED:
Psychiatric/ Suicidal History: Current Mental Disorder (especially Mood
Disorder)
Military Service: Eligibility: NSC
VERIFIED
Exposure to extreme stress
Financial issues: Financial stressors, Job Loss/Change/Inability to
acquire a job
Medical issues: Chronic Pain, Other:
Chronic medical problems.
Veteran states he can't keep a job or relationships
and
has no income currently. He states he has been homeless frequently in the last
3-4 years and is staying with a friend temporarily. He anticipates he will have
to leave soon because he isn't contributing money. He only has food stamps.
I
discussed the Domicillary and Transitional Living. I also told him about the
HUD/VASH Program though he wouldn't qualify at this time. I gave him to
applications for Haven Recovery and the Domicillary. He had been turned down
for VA Compensation several years ago even though he was in the hospital while
in the service after a car accident. He has flashbacks about it. I suggested he
go to a Veteran's Benefit Counselor and re-apply. He said he has pain in his
back, knees. He states he doesn't trust people and has trouble socially.
He
may need to apply for SSDI as well.
PLAN OF CARE: Veteran is to return the applications if interested. Will set up a
follow up appt. in one month.
The patient has been involved in the development of this plan of care and
concurs with such.
Educated patient/family regarding treatment plan and its
purpose/risk/benefits/effects; provided opportunity for questions.
Patient/caregiver voiced understanding of information.
Time Spent:( )20-30 minutes ( X)50-60 minutes ( )other:
There is
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