A big fat denial

[tylerb333]

Does this sound or look right to anyone?  Denied TDIU...

 

=========================================================================

Date/Time:               20 Jun 2017 @ 0800

Note Title:              C&P MENTAL DISORDER

Location:                Chalmers P Wylie VA Outpatnt

Signed By:               HOULE,ALLISON C

Co-signed By:            HOULE,ALLISON C

Date/Time Signed:        20 Jun 2017 @ 1641

-------------------------------------------------------------------------

 

 LOCAL TITLE: C&P MENTAL DISORDER                               

STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT        

DATE OF NOTE: JUN 20, 2017@08:00     ENTRY DATE: JUN 20, 2017@16:41:06     

      AUTHOR: HOULE,ALLISON C      EXP COSIGNER:                          

     URGENCY:                            STATUS: COMPLETED                    

 

   *** C&P MENTAL DISORDER Has ADDENDA ***

 

 

                  Review Post Traumatic Stress Disorder (PTSD)

                        Disability Benefits Questionnaire

 

    Name of patient/Veteran:   xxxxxxx

   

    Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

    Request?

    [X] Yes  [ ] No

   

 

                                   SECTION I:

                                   ----------

    1. Diagnostic Summary

    ---------------------

    Does the Veteran now have or has he/she ever been diagnosed with PTSD?

    [X] Yes  [ ] No

 

    2. Current Diagnoses

    --------------------

    a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder

         ICD Code: F43.10

 

       Mental Disorder Diagnosis #2: Opioid Use Disorder, Severe, In early

          remission, on maintenance therapy

         ICD Code: F11.20

 

    b. Medical diagnoses relevant to the understanding or management of the

       Mental Health Disorder (to include TBI):

       No response provided.

      

    3. Differentiation of symptoms

    ------------------------------

    a. Does the Veteran have more than one mental disorder diagnosed?

       [X] Yes  [ ] No

      

    b. Is it possible to differentiate what symptom(s) is/are attributable to

       each diagnosis?

       [X] Yes  [ ] No  [ ] Not applicable (N/A)

      

           If yes, list which symptoms are attributable to each diagnosis and

           discuss whether there is any clinical association between these

           diagnoses: The veteran's symptoms are primarily related to his PTSD

           since he has not used substances in more than six months.

          

    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

       [ ] Yes  [X] No  [ ] 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 reduced reliability and

           productivity

 

    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?

       [X] Yes  [ ] No  [ ] No other mental disorder has been diagnosed

      

           If yes, list which portion of the indicated level of occupational and

           social impairment is attributable to each diagnosis: The veteran's

           impairment is related to his PTSD.

          

    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

    ------------------

    Evidence reviewed (check all that apply):

   

    [X] VA e-folder (VBMS or Virtual VA)

    [X] CPRS

 

    Evidence Comments:

      The veteran's electronic medical records (CPRS & VistAWeb) and military

      records (VBMS) were reviewed.

 

      The veteran was referred for a compensation and pension examination. The

      veteran was informed verbally of the nature and purpose of the examination

      and confidentiality limits. He appeared to have a basic understanding of

      the purpose of the examination and confidentiality limits. He was provided

      with a chance to ask questions about the evaluation procedures. All

      questions were answered to reasonable satisfaction or referred to other

      resources. He was informed that this examiner is not his treating

clinician

      or the legal determiner of compensation or pension benefits. Instead, he

      was informed that this examiner is an independent provider of clinical

      information and expertise to assist those who review and make legal

      compensation and pension claim decisions and would not be participating in

      her healthcare. He was given information about the Veteran's 24-hour

Crisis

      Line. The veteran indicated understanding of these terms and explicitly

and

      freely consented to the evaluation. The judgments of symptoms and opinions

      in this evaluation report are offered to a reasonable degree of

      psychological certainty and are only based upon the information available

      at the time of the evaluation.

 

      This report was dictated using Dragon Naturally Speaking dictation

      software. The report has been proofread; however, there still may be some

      typographical errors due to the nature of the dictation software.

 

      The veteran began participating in recovery services at the VA in May

2017.

      His last group note was dated 5/31/17.

 

      A note dated 2/26/17, by Dr. Laurie Berger, indicates that the veteran

      began therapy at the Vet Center in October 2016. He attends therapy on a

      weekly basis. He attended six sessions with Dr. Berger when this note was

      written.

 

      The veteran was initially evaluated for a C&P exam by Dr. Janine Schroeder

      on 3/22/17.

     

 

    2. Recent History (since prior exam)

    ------------------------------------

    a. Relevant Social/Marital/Family history:

          The veteran was born and raised in xxxx. He was raised by

his

          mother and father until they divorced when he was 7 years old. The

          veteran then lived with his mother until he was 14 years old. The

          veteran's mother remarried when he was 11 years old and he reported

          that he did not get along well with his stepfather. He went to live

          with his father at 14 years of age due to being disrespectful towards

          his stepfather. The veteran has one older sister and one younger

          brother. The veteran's father did not remarry, but he was in a

          relationship with the same woman for 20 years. He reported physical

          abuse by his father throughout his adolescent years. He recalled one

          incident where he got a black eye after his father hit him. He denied

          any Child Protective Services involvement. The veteran describes his

          father as emotionally absent. His father died in 2007 from a heart

          attack.

 

          The veteran is a 36-year-old, divorced male. He was married in 2001

for

          five years and divorced in 2006. The veteran reported that they

          divorced due to his drug use. They have a 1X-year-old daughter

          together. His ex-wife and daughter live in xxxxx. He

          maintained some contact with his daughter, but has not seen her in

          several years. The veteran reported that he was involved in a

          relationship for a few years following his divorce. They are no longer

          in a relationship, but are close friends.

 

          The veteran reported that he has spends time with three friends from

          high school. The veteran stated that he enjoys gardening.

         

    b. Relevant Occupational and Educational history:

          The veteran reported that he did not enjoy school and did not want to

        

 do the work. He frequently skipped school to go skating. He stated that

          he would "have a few beers and smoked pot" when he skipped school. He

          reported being suspended several times for truancy, fighting, and

          disrespect towards teachers. He was never held back a grade. He was

          expelled his junior year of high school due to nonattendance. He

earned

          his GED in 1997.

          The veteran worked for his father from 1997 until 1999 doing ironwork.

 

          The veteran enlisted in the Navy in October 1999. He reported several

          disciplinary issues while in the service related to going AWOL, being

          late, and underage drinking. He reported that the sexual assault

          occurred in the summer of 2001. The veteran received a general under

          honorable conditions discharge in September 2001 for misconduct.

 

          The veteran worked in Virginia Beach beginning in September 2001 doing

          ironwork. He worked at a company for one year and was fired due to not

          showing up for work and using alcohol and drugs. He then worked for

          Roofing Services Incorporated from September 2002 until August 2003.

          The veteran then earned his tanker men certification, z card, and AB

          certification to work on tugboats. He worked on boats from September

          2003 until March 2005. At that time his wife left him and he moved

back

          to Ohio to be closer to his family. The veteran continued working on

          boats in Ohio until the summer of 2005 when he got fired. The veteran

          was incarcerated from 2006 until 2016. After his release from prison,

          he worked with friends doing landscaping and painting. He began

working

          at ABS Money Systems in January 2017, a company that his mother owns.

          The veteran reported that he was working 30-40 hours per week for the

          first two months. He stated that his hours have declined significantly

          since March and he is currently working 5-6 hours per week. He stated

          that his work has declined due to his mental health symptoms. However,

          according to the initial C & P exam, "he is unable to do a lot for her

          because she works serving ATM machines in banks and with his record he

          isn't allowed to work in banks." He also reported that his employment

          since the military has been "short-lived due to his drug and alcohol

          use."

         

         

    c. Relevant Mental Health history, to include prescribed medications and

       family mental health:

          The veteran reported that he was diagnosed with ADHD during childhood

          and received treatment. The veteran reported a suicide attempt in 2001

          after he was discharged from the military. He began attending

treatment

          at the Vet Center in October 2016. He reported that he attends

          individual therapy twice per week with Dr. Berger. The veteran

          described his mood as "anxious, paranoid, and depressed." He stated

          that he feels as though he "can't get a break." He reported having

          passive thoughts of suicide, but stated that he does not have a plan

or

          intention to kill himself. He stated "I couldn't do that to my

family."

          He stated that he has had difficulty dealing with his emotions since

he

          is no longer using substances and does not have an escape. He stated

"I

          don't have the coping skills." He described having difficulty sleeping

          and stated that he does not sleep every night. He stated that he is

not

          feel safe in his bed.

         

    d. Relevant Legal and Behavioral history:

          The veteran reported that he had several misdemeanor offenses as a

          juvenile, including truancy, driving without a license, and theft. He

          reported that he was arrested for selling drugs at 18 years of age and

          was placed on probation for one year. According to the previous exam,

          he was arrested numerous times from June 1998 to September 1999. The

          veteran was convicted of armed robbery for robbing three pharmacies

          with a weapon. He served a 10-year prison sentence beginning in

October

          2006 and was released in September 2016. He is currently on parole for

          five years.

         

    e. Relevant Substance abuse history:

          The veteran reported that he first drank alcohol at 10 years of age.

He

          began regularly drinking alcohol during high school. He began smoking

          marijuana at 15 years of age on the weekends. He also experimented

with

          mushrooms and pain/anxiety medication that he took from his father.

The

          veteran's alcohol use increased significantly while in the military.

He

          denied using any drugs while in the service. After his discharge from

          the service, he continued using alcohol and marijuana. In 2002, he

          began using narcotic pain medication. He also began using heroin and

          reported that he eventually used heroin intravenously. The veteran

          reported using substances throughout his time in prison. He reported

          that he has been clean from drugs and alcohol since October 2016. He

          has maintained sobriety using Suboxone. He currently attends AA

          meetings approximately once per week. He attends substance abuse

groups

          at the VA twice per month.

         

    f. Other, if any:

       No response provided.

      

    3. PTSD Diagnostic Criteria

    ---------------------------

 

    Please check criteria used for establishing the current PTSD diagnosis. The

    diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual

    of Mental Disorders, 5th edition (DSM-5).  The stressful event can be due to

    combat, personal trauma, other life threatening situations (non-combat

    related stressors).  Do NOT mark symptoms below that are clearly not

    attributable to the Criterion A stressor/PTSD.  Instead, overlapping

symptoms

    clearly attributable to other things should be noted under #6 - "Other

    symptoms".

   

       Criterion A: Exposure to actual or threatened a) death, b) serious

injury,

                    c) sexual violence, in one or more of the following ways:

                   

                   [X] Directly experiencing the traumatic event(s)

 

       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] Dissociative reactions (e.g., flashbacks) in which the

                       individual feels or acts as if the traumatic event(s)

were

                       recurring.  (Such reactions may occur on a continuum,

with

                       the most extreme expression being a complete loss of

                       awareness of present surroundings).

                   [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 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).

 

       Criterion 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, distorted cognitions about the cause or

                       consequences of the traumatic event(s) that lead the

                       individual to blame himself/herself or others.

                   [X] Persistent negative emotional state (e.g., fear, horror,

                       anger, guilt, or shame).

                   [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)

of

                    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] Exaggerated startle response.

                   [X] Problems with concentration.

                   [X] Sleep disturbance (e.g., difficulty falling or staying

                       asleep or restless sleep).

 

       Criterion F:

                   [X] The duration of the symptoms described above in Criteria

                       B, C, and D are more than 1 month.

 

       Criterion G:

                   [X] The PTSD symptoms described above cause 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.

 

    4. Symptoms

    -----------

    For VA rating purposes, check all symptoms that actively apply to the

    Veteran's diagnoses:

   

       [X] Depressed mood

       [X] Anxiety

       [X] Suspiciousness

       [X] Chronic sleep impairment

       [X] Disturbances of motivation and mood

       [X] Difficulty in establishing and maintaining effective work and social

           relationships

 

    5. Behavioral observations

    --------------------------

       The veteran arrived 10 minutes late for his appointment and was pleasant

       upon meeting. The veteran was oriented to person, place, situation, and

       time. His grooming and hygiene were adequate. He made appropriate eye

       contact and presented with a depressed mood with a congruent affect. His

       speech was within normal limits for tone, volume, and rate. His thoughts

       were logical, linear, and goal-directed. He did not evidence any

psychotic

       symptoms, including responding to auditory or visual hallucinations and

       delusional beliefs.

       

       On a brief mental status exam he was able to freely recall two of three

       words presented after a brief delay. He was able to recall six digits

       forward and three digits backward. He was able to complete a serial seven

       subtraction task with no errors to seven places. He was able to spell the

       word WORLD forwards and backwards. He was able to complete a two-digit

       addition and subtraction tasks. He was able to compare an apple and

banana

       and was able to reason abstractly when comparing a poem and a statue. His

       response to the proverb "don't cry over spilled milk" was good. He was

not

       able to provide a response to the proverb "people in glass houses should

       not throw stones."

      

      

    6. Other symptoms

    -----------------

    Does the Veteran have any other symptoms attributable to PTSD (and other

    mental disorders) that are not listed above?

    [ ] Yes  [X] No

   

    7. Competency

    -------------

    Is the Veteran capable of managing his or her financial affairs?

    [X] Yes  [ ] No

   

    8. Remarks, (including any testing results) if any:

    ---------------------------------------------------

       The veteran was administered a psychological measurement that is useful

       for interpreting the veracity of other data provided by an examinee

during

       a psychological or neuropsychological examination. This assessment can

       assist in evaluating and making a clinical opinion regarding the veracity

       of an examinee's purported symptoms. Research has determined that this

       tool is a useful instrument to administer in order to screen for possible

       feigning of PTSD symptoms. The following results should be interpreted in

       light of the fact that the measurement that was chosen is a screening

tool

       and not designed as a definitive measure of whether or not an individual

       is feigning mental illness. The Veteran's total score was not elevated

       beyond the cut-off score. Therefore, his PTSD symptoms are considered to

       be credible.

 

       The veteran was administered the Minnesota Multiphasic Personality

       Instrument-2-Restructred Form (MMPI-2-RF), which is a self-report

       psychological assessment used to identify a variety of psychological

       syndromes. The veteran was provided a quiet, private room to complete the

       testing. It appears the veteran understood the items and responded to the

       items in a consistent manner. The veteran over-reported psychological

       dysfunction, which is evidenced by a considerably larger than average

       number of infrequent responses. The veteran also possibly overreported

       symptoms associated with non-credible memory complaints. Although there

is

       evidence of over reporting of symptoms, the profile is considered valid

       and will be interpreted.

 

       Overall, the veteran endorsed considerable emotional distress that is

       likely perceived as a crisis. The veteran reported feeling sad and

       dissatisfied with his currently circumstances. He reported a lack of

       positive emotional experiences, a lack of energy, and a lack of interest

       in activities. He also reported experiencing various negative emotional

       experiences including anxiety, anger, and fear. The veteran also reported

       a significant history of antisocial behavior. This behavior includes

       involvement with the criminal justice system, difficulty with authority

       figures, conflictual interpersonal relationships, impulsivity, juvenile

       delinquency, and substance abuse. The veteran also endorsed various

       unusual thought and perceptual processes.

 

       The veteran endorsed a diffuse pattern of cognitive difficulties

including

       memory complaints. He also reported past suicidal ideation and feelings

of

       helplessness. The veteran endorsed feelings of anxiety, being anger

prone,

       and experiencing multiple fears that restrict his activity inside and

 

 

       outside of the home. He also reported being unassertive and shy. The

       veteran endorsed not enjoying social events and avoiding social

       situations. He also reported disliking being around people. On a scale of

       personality pathology, the veteran endorsed being self-critical and

       guilt-prone. He also endorsed being pessimistic and feeling depressed.

 

       The veteran is currently diagnosed with Posttraumatic Stress Disorder and

       Opioid Use Disorder, Severe, In early remission, on maintenance therapy.

       The veteran currently lives alone and is not involved in a romantic

       relationship. He maintains phone contact with his daughter. He has a

close

       relationship with his mother, sister, and two friends. He is currently

       working for his mother's company. He reported experiencing symptoms of

       PTSD. He is attempting to cope with his emotions without the use of

drugs.

       

 

       The veteran has been employed numerous times and has been fired for

       tardiness or alcohol and drug use. He is currently working 5-6 hours per

       week for his mother's company. According to the previous C&P exam, he is

       not able to work many hours due to not being permitted to work inside of

a

       bank due to his felony record. The veteran reported that he was "working"

       during his 10 years in prison selling drugs. He denied having any

       difficulties while in prison. The veteran is capable of following

       instructions and performing simple tasks. He is able to concentrate on a

       simple task and respond appropriately to coworkers and supervisors. 

 

 

      

      

 

 

/es/ ALLISON C HOULE, PHD

C&P Psychologist

Signed: 06/20/2017 16:41

 

06/20/2017 ADDENDUM                      STATUS: COMPLETED

The veteran presented for his appointment. The report from the C&P Exam was

completed in Capri by Allison Houle, PhD; procedure code 99456 and 96101.

 

/es/ ALLISON C HOULE, PHD

C&P Psychologist

Signed: 06/20/2017 16:42

[Gastone]

Where is the redacted IU Denial Letter? We need to see the Reasons for the Denial, as well as Evidence Review.

A very large majority of IU Denials are based on Evidence of ability to do any type of "Sedentary Employment" that would provide Earned Income in excess of the VA SGI of $12,440 per year if under 65, $11,440 over 65.

Post a redacted copy of the IU Denial Letter. Have you Filed your NOD yet? consider Applying to the VA Vocational Rehabilitation Dept on E-Ben. Get a Professional VRC's opinion as to your Employability. A VRC Denial Letter could make or break your Appeal and would be considered as the Mandated submission of "New & Material Evidence" required for both the DRO Review or Hearing route.

[Guest L]

@tylerb333 Hi , just an observation from reading the C& P - and as @Gastone notes - the IU denial letter is needed. 

My degree is Criminology and "reentry" from prison to jail is my interest.

I have just been trained and will start with Female Veterans in my county jail, who are in similar circumstances. 

I see you have the ability to garden/ landscaping-  and assist in other ways with work environment, your conviction is limiting your job application/ placements per your statement. 

Just as a simple observation: Respectfully stated,  you're not "Unemployable" due to your rating, it is more from a society/ law enforcement perspective.

                                            10 years incarceration is a felony conviction which precludes a lot of jobs and there  is bias in society.

You would be better served to sign up for a "Reentry" program in your area. You can seek this resource out through the Veterans Court in your county.                      This is free. 

Message me if you need help, I would be happy to give you ideas. see link below. 

 https://www.indeed.com/q-Felony-Friendly-Jobs-l-Texas-jobs.html

Best of Luck

I know this is not the answer to your question .... Hopefully you will see my point, if.... the denial is not reversed. 

 

[broncovet]

It usually boils down to evidence, and it appears what you have so far falls short.  You need your doctor to state that you are "unable to maintain SGE due to service connected conditions."  This report does not come out and say that, but comes somewhat close.  "Close" means no cigar in VAspeak.  

My suggestion is to file a NOD, and get more evidence either by a VA doc, voc rehab specialist, IME/IMO, or some combination of these that states what I mentioned above.  

When you read your reports and exams, look for those words IN BOLD, above.  If they dont read those words, they deny.  

[Gastone]

The C & P Clinician's discussion regarding over-Reporting of PTSD Symptoms has to give one pause. She indicated you didn't quite make Malingering cut, but it sounded like you got fairly close, that is not good.  You certainly have some MH issues, but your employment/lifestyle choices and Drug usage, appear to be the same as before you entered the Navy.

This recent PTSD DBQ certainly doesn't support a VA IU Award. You're obviously capable of some/any sort of "Sedentary Employment" that would provide in excess of the VA SGI $12,440 per year. That's $249.00 per week, $6.22 per hr for 50;  40 hr weeks.

[tylerb333]

The Psychologists opinion is correct: I am able to follow directions and complete simple tasks.  But she errs in her judgement in three regards: 1) I am only able to keep and hold a job for a brief period before my PTSD symptoms present as is evidenced in my medical records with respect to my attending groups and hospitalizations.   When my symptoms present I am unable to sleep. I become erratic, and hear voices, become paranoid, sometimes attempting suicide.  This in and of itself lends itself more times than not to my being dismissed or fired.  I eventually relapse to get relief from my symptoms.  This leads to sustained use and dependence.  2) I can respond appropriately to coworkers as Dr. Houle suggests, but as I previously mentioned, the PTSD symptoms present, and I am unable to sleep, I become erratic, and I hear voices, I become paranoid, and to suggest I can maintain relationships at work while exhibiting these behaviors is asinine. 3) Dr. Houle suggests that drugs are my problem and that I am not service connected for drug use is just false.  I am service connected for drug abuse disorder, a secondary condition to my PTSD (Military Sexual Trauma).  Additionally, she states my inability to hold a job is due to that very thing, opioid use disorder.

 

Additionally, I attended said treatment and was dx'd for behavior.  That VA left me 1000 miles away without shelter or a plane ride home.  I ended up in their VA hospital as a result of a suicide attempt...  Since that time I've attempted suicide one other time, that is, twice in 3 mos, and I am currently hospitalized.  Do you think in light of these circumstances I would have a shot at IU in the ramp program?

Edited June 29, 2018 by tylerb333

[tylerb333]

Note Title:              SUICIDE BEHAVIOR REPORT

Location:                Chillicothe OH VAMC

Signed By:               HINES,JEENEE M

Co-signed By:            HINES,JEENEE M

Date/Time Signed:        18 Jun 2018 @ 1007

-------------------------------------------------------------------------

 

 LOCAL TITLE: SUICIDE BEHAVIOR REPORT                           

STANDARD TITLE: SUICIDE RISK ASSESSMENT NOTE                   

DATE OF NOTE: JUN 18, 2018@10:03     ENTRY DATE: JUN 18, 2018@10:04:06     

      AUTHOR: HINES,JEENEE M       EXP COSIGNER:                          

     URGENCY:                            STATUS: COMPLETED                    

 

 

   DOB: JUL 22,1980 (37)

 

 

-- Date/Time of event:

 

   Jun 13,2018@22:00  (Time is approximate)

 

   Location of event: Off station

 

   Patient status at time of event: Outpatient

 

   Outcome of event:     remained outpt, hospitalized: indicate where in

the box below

          voluntarily came to UC day after

 

 

-- Source of information: Written,     Patient self-report

 

   Name & Phone # of source: veteran

 

-- Patient's stated: Level of INTENT of this event was: High

 

   Staff assessment: Level of INTENT of this event was: High

 

   Staff assessment: Level of LETHALITY of this event was: Low

 

   Last Pain Score Before Event: 6

 

   Did the patient have access to firearms? Unknown

 

   Description of event: struggling with depression and positive for

suicidal ideation, made an attempt  at overdose on quetiapine and alcohol

 

   Past 10 Clinic Visits:

06/17/2018 12:40  CHI MH INPT PSY 21-45MIN                UNSCHEDULED

06/16/2018 14:31  CHI MH INPT PSY 21-45MIN                UNSCHEDULED

06/15/2018 13:00  CHI RECREATION GROUP 2                  UNSCHEDULED

06/15/2018 12:46  CHI PHARM INPT MH                       UNSCHEDULED

06/15/2018 09:03  CHI MH INPT PSY 21-45MIN                UNSCHEDULED

06/15/2018 09:00  CHI TCM CARE MANAGEMENT R               UNSCHEDULED

06/14/2018 12:37  CHI MH URGENT CARE 8-4 1

01/03/2018 15:30  CHI TELE MHRRTP                         UNSCHEDULED

12/20/2017 15:55  CHI PRRTP NP                            UNSCHEDULED

12/20/2017 13:30  CHI PM&RS PHYSICIAN INPAT               CANCELLED BY

CLINIC

 

-- Patient is currently receiving treatment in the following areas:

       Ambulatory Care

 

   Primary Care Provider:  COPC

 

   Case Manager/Therapist: COPC

 

   Name of Provider prescribing psychiatric medications:COPC

 

 

Active problems - Computerized Problem List is the source for the

following:

 

 1. Cocaine dependence (SNOMED CT 31956009)

 2. AA - Alcohol abuse (SNOMED CT 15167005)

 3. Cannabis dependence (SNOMED CT 85005007)

 4. Low back pain (SNOMED CT 279039007)

 5. Chronic post-traumatic stress disorder

 6. Opioid dependence

-- BRIEF PLAN/DISPOSITION:

       Developed crisis management plan, Medication management, Refer for

Mental Health treatment, Assure followup appointment is made

 

 

/es/ JEENEE M HINES, LISW-S

CLINICAL SOCIAL WORKER

Signed: 06/18/2018 10:07

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