ptsd PTSD c&p

[Stardust]

So this was the results from my exam. I'm not sure why he said I wasn't capable of managing my finances. 

 

 

VA Notes
Source: VA
Last Updated: 29 Apr 2016 @ 0642
Sorted By: Date/Time (Descending)
VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed
and signed by all required members of your VA health care team. If you have any questions about your
information please visit the FAQs or contact your VA health care team.
Date/Time: 26 Apr 2016 @ 1330
Note Title: C&P EXAM
Location: Columbia SC VAMC
Date/Time Signed: 26 Apr 2016
Note
 LOCAL TITLE: C&P EXAM 
STANDARD TITLE: C & P EXAMINATION NOTE 
DATE OF NOTE: APR 26, 2016@13:30 ENTRY DATE: APR 26, 2016@14:09:53 
 
 URGENCY: STATUS: COMPLETED 
 Initial Post Traumatic Stress Disorder (PTSD)
 Disability Benefits Questionnaire
 * Internal VA or DoD Use Only *
 Name of patient/Veteran: 

 SECTION I:
 ----------
 1. Diagnostic Summary
 ---------------------
 Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
 based on today's evaluation?
 [X] Yes [ ] No
 
 2. Current Diagnoses
 --------------------
 a. Mental Disorder Diagnosis #1: PTSD
 b. Medical diagnoses relevant to the understanding or management of the
 Mental Health Disorder (to include TBI):
 No response provided.
CONFIDENTIAL Page 4 of 70

 Differentiation of symptoms
 ------------------------------
 a. Does the Veteran have more than one mental disorder diagnosed?
 [ ] Yes [X] No
 
 c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
 [ ] Yes [ ] No [X] Not shown in records reviewed
 
 4. Occupational and social impairment
 -------------------------------------
 a. Which of the following best summarizes the Veteran's level of 
occupational
 and social impairment with regards to all mental diagnoses? (Check only
 one)
 [X] 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
 b. For the indicated level of occupational and social impairment, is it
 possible to differentiate what portion of the occupational and social
 impairment indicated above is caused by each mental disorder?
 [ ] Yes [ ] No [X] No other mental disorder has been diagnosed
 
 c. If a diagnosis of TBI exists, is it possible to differentiate what 
portion
 of the occupational and social impairment indicated above is caused by 
the
 TBI?
 [ ] Yes [ ] No [X] No diagnosis of TBI
 
 SECTION II:
 -----------
 Clinical Findings:
 ------------------
 1. Evidence review
 ------------------
 In order to provide an accurate medical opinion, the Veteran's claims 
folder
 must be reviewed.
 
 a. Medical record review:
 -------------------------
 Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
 [X] Yes [ ] No
 
 Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
 [ ] Yes [ ] No
 
 If yes, list any records that were reviewed but were not included in the

No changes in history from 2015 exam. Veteran works at the VA clinic 
x
 1 year. She works in the lab. She reports works as "okay." 
She reports
 that for the most part she is functioning well at work. She reports
 that her co-workers are supportive.
 
 c. Relevant Mental Health history, to include prescribed medications and
 family mental health (pre-military, military, and post-military):
 No changes in history from 2015 exam. Veteran is receiving care 
through
 the VA. She receives individual counseling on a weekly basis. She is
 involved in medication management with fluoxetine 40mg, trazodone as
 needed, and prazosin 2mg. Veteran reports she started medicationo
 management again in February 2016, she had previously been on the
 medication but had stopped for some time. She reported that symptoms
 worsened off the medications.
 
 d. Relevant Legal and Behavioral history (pre-military, military, and
 post-military):
 No changes in history from 2015 exam. none
 
 e. Relevant Substance abuse history (pre-military, military, and
 post-military):
 No changes in history from 2015 exam. Alcohol- Veteran reports she 
has
 cut back on her alcohol use. She reports drinking about 2 days per 
week
 over the last 2-3 months, was drinking heavily prior to this. She
 reports she will now have 1-2 drinks with dinner a couple of days per
 week. No illicit drug use.
 
 f. Other, if any:
 No response provided.
 
 3. Stressors
 ------------
 Describe one or more specific stressor event(s) the Veteran considers
 traumatic (may be pre-military, military, or post-military):
 
 a. Stressor #1: Veteran reports MST that occurred in 2004 while she was in
 basic training. Veteran states she was called to the drill 
instructor,
 she states she had some problems earlier that day in the cafeteria so
 she thought this is what it was about. She states that when she went
 to his room he closed the door to his office and began acting
 
 inappropriately with her. She reports that she was raped in his
 office. Veteran states that she told another drill instructor the next
 day and was told to keep it quiet. She states that the drill 
instructor
 that assaulted her left the barracks for a few weeks. was seen at the cliniic two days later for a broken finger and also
 seen for STD evaluation. She states she was then followed for unsafe
 sexual practices.
 
 Does this stressor meet Criterion A (i.e., is it adequate to support
 the diagnosis of PTSD)?
 [X] Yes [ ] No
 
 Is the stressor related to the Veteran's fear of hostile military 
or
 terrorist activity?
 [ ] Yes [X] No
 
 Is the stressor related to personal assault, e.g. military sexual
 trauma?
 [X] Yes [ ] No
 
 If yes, please describe the markers that may substantiate the
 stressor.
 Veteran received treatment at the clinic with STD testing.
 Veteran states she failed out of her medic class. Veteran states
 she had to take classes for anxiety.
 
 b. Stressor #2: Veteran served in Iraq in 2009, she was stationed in Bilad.
 Veteran states that within the first week she was there the base took
 incoming mortar attacks. Veteran states that she was sleeping in a
 tent. The mortar hit a large trash dumpster near her. Veteran states
 she was fearful for her safety.
 
 Does this stressor meet Criterion A (i.e., is it adequate to support
 the diagnosis of PTSD)?
 [X] Yes [ ] No
 
 Is the stressor related to the Veteran's fear of hostile military 
or
 terrorist activity?
 [X] Yes [ ] No
 
 Is the stressor related to personal assault, e.g. military sexual
 trauma?
 [ ] Yes [X] No
 
 4. PTSD Diagnostic Criteria
 ---------------------------
 Please check criteria used for establishing the current PTSD diagnosis. Do
 NOT mark symptoms below that are clearly not attributable to the Criteria A
 stressor/PTSD. Instead, overlapping symptoms clearly attributable to other
 things should be noted under #7 - Other symptoms. The diagnostic criteria
 for PTSD, referred to as Criteria A-H, are from the Diagnostic and
 Statistical Manual of Mental Disorders, 5th edition (DSM-5).
 
 Criterion A: Exposure to actual or threatened a) death, b) serious

injury,
 c) sexual violation, in one or more of the following ways:
 [X] Directly experiencing the traumatic event(s)
 [X] Witnessing, in person, the traumatic event(s) as they occurred to
 others
 Criterion B: Presence of (one or more) of the following intrusion 
symptoms
 associated with the traumatic event(s), beginning after the
 traumatic event(s) occurred:
 [X] Recurrent, involuntary, and intrusive distressing memories of the
 traumatic event(s).
 [X] Recurrent distressing dreams in which the content and/or affect of
 the dream are related to the traumatic event(s).
 [X] Intense or prolonged psychological distress at exposure to 
internal
 or external cues that symbolize or resemble an aspect of the
 traumatic event(s).
 [X] Marked physiological reactions to internal or external cues that
 symbolize or resemble an aspect of the traumatic event(s).
 Criterion C: Persistent avoidance of stimuli associated with the 
traumatic
 event(s), beginning after the traumatic events(s) occurred,
 as evidenced by one or both of the following:
 [X] Avoidance of or efforts to avoid distressing memories, thoughts, 
or
 feelings about or closely associated with the traumatic event(s).
 [X] Avoidance of or efforts to avoid external reminders (people,
 places, conversations, activities, objects, situations) that 
arouse
 distressing memories, thoughts, or feelings about or closely
 associated with the traumatic event(s).
 Criterion D: Negative alterations in cognitions and mood associated with
 the traumatic event(s), beginning or worsening after the
 traumatic event(s) occurred, as evidenced by two (or more) 
of
 the following:
 [X] Persistent negative emotional state (e.g., fear, horror, anger,
 guilt, or shame).
 [X] Markedly diminished interest or participation in significant
 activities.
 [X] Feelings of detachment or estrangement from others.
 [X] Persistent inability to experience positive emotions (e.g.,
 inability to experience happiness, satisfaction, or loving
 feelings.)
 Criterion E: Marked alterations in arousal and reactivity associated with
 the traumatic event(s), beginning or worsening after the
 traumatic event(s) occurred, as evidenced by two (or more)

the following:
 [X] Irritable behavior and angry outbursts (with little or no
 provocation) typically expressed as verbal or physical aggression
 toward people or objects.
 [X] Hypervigilance.
 [X] Problems with concentration.
 [X] Sleep disturbance (e.g., difficulty falling or staying asleep or
 restless sleep).
 Criterion F:
 [X] Duration of the disturbance (Criteria B, C, D, and E) is more than
 1 month.
 
 Criterion G:
 [X] The disturbance causes clinically significant distress or
 impairment in social, occupational, or other important areas of
 functioning.
 
 Criterion H:
 [X] The disturbance is not attributable to the physiological effects 
of
 a substance (e.g., medication, alcohol) or another medical
 condition.
 
 Criterion I: Which stressor(s) contributed to the Veteran's PTSD
 diagnosis?:
 [X] Stressor #1
 [X] Stressor #2
 5. Symptoms
 -----------
 For VA rating purposes, check all symptoms that actively apply to the
 Veteran's diagnoses:
 
 [X] Depressed mood
 [X] Anxiety
 [X] Chronic sleep impairment
 [X] Disturbances of motivation and mood
 [X] Difficulty in adapting to stressful circumstances, including work or 
a
 worklike setting
 [X] Suicidal ideation
 6. Behavioral Observations
 --------------------------
 anxious, tearful at times.
 7. Other symptoms
 -----------------
 No response provided
 
 8. Competency

Is the Veteran capable of managing his or her financial affairs?
 [ ] Yes [X] No
 
 9. Remarks, (including any testing results) if any
 --------------------------------------------------
 The veteran meets diagnostic criteria for PTSD. Veterans anxiety and
 depression symptoms reported on 2015 examination were consistent with 
PTSD
 but full criteria not met, Veteran currently meets criteria. The 
veteran's
 PTSD is at least as likely as not related to her reported military
 stressors. Veteran reports combat stressors and MST. The veteran's 
record
 indicates markers that in my opinion are consistent with MST.
 
 NOTE: VA may request additional medical information, including additional
 examinations if necessary to complete VA's review of the Veteran's
 application.
/es/

[Buck52]

not being able to manage your finances is Bad on the box he checked yes to.

you can request another exam or ask that the  part ''can veteran manage own finances is untrue  let them know you can...if you can?

My PTSD report was similar to this  but I have good Hygiene and can manage my own finances  and was given a 70% rating.

..........Buck

[Stardust]

48 minutes ago, Buck52 said:

not being able to manage your finances is Bad on the box he checked yes to.

you can request another exam or ask that the  part ''can veteran manage own finances is untrue  let them know you can...if you can?

My PTSD report was similar to this  but I have good Hygiene and can manage my own finances  and was given a 70% rating.

..........Buck

I am certain it was a mistake. Do I wait until I get a final decision or will the rater go over everything before I actually get a rating. 

[flores97]

Stardust, I would challenge the incompetency portion of the exam immediately. Do not wait. Do you have any idea at all as to why the examiner marked that box? Was this a contracted exam, through QTC, VES, or at one of the local VAMCs? If it was done at a Vamc, i would speak to a patient advocate and ask if its possible for them to contact the examiner and ask if that was in error. If it was done through qtc or ves, it may be possible to contact them and ask them the same question. I would try to provide proof of your capacity to handle finances, provide copies of up to date bills, etc. You might also consider contacting your local congressman as well. I have a buddy that this situation happened to, she went the route I suggested and was successful, the examiner corrected his mistake and stated the vets he had examined before her were incompetent to handle finances, but I think that she was very lucky the examiner was willing to admit that. I'm sure other members will comment as well, best of luck and I'm sorry for what you went through in service to our country.

[Stardust]

I have no clue as to why he said that. I have attempted to contact the Columbia VA . Like I said before we didn't even talk about money. We briefly talked about my current job with the VA. But it was mostly about the MST.

[flores97]

Stardust, if the c&p was held at the VA, go in asap and talk to a patient advocate, explain the situation, try to bring a copy of the exam with you, as well as up to date copies of bills, etc. You could also talk to a vet rep at the VA benefits office in the vamc, but i would try the patient advocate first. If you are in MH therapy, see if your MH Doctor would write a brief statement on your competence to handle your finances, and submit one copy to your Regiinal Office asap, bring the other copy with you if possible when you speak to the advocate. Good Luck!

[Stardust]

Will do. Thank you and I will keep you posted.