Adequacy of the Comprehensive Clinical Evaluation Program: A Focused Assessment (1997)

At the MTF level, the CCEP record should include all CCEP forms and relevant medical data to the program.

Blank forms included with this guide supersede previous editions of these forms and are intended to be used with the new CCEP.

All individual forms will be complete and legible.

Forms forwarded to NMIMC and maintained in the participant record shall be in the following order:

MTF Phase I Diagnosis Form

Patient Questionnaire

Provider-Administered Symptom Questionnaire

Information Release Form

Declination/Completion Form

RMC Phase II Diagnosis Form

Declination/Completion Form

The CCEP is based upon a thorough clinical evaluation which emphasizes comprehensive and continuous primary care. The local MTF primary care provider maintains responsibility for patient evaluation and care throughout the CCEP process.

Phase I will consist of a comprehensive history and medical evaluation with completion of Phase I questionnaires and related forms. The examination, both in content and quality, should parallel an inpatient admission work-up. The Phase I examination will include a complete medical history including: family, occupation, social (including tobacco, alcohol, and drug use), exposure to possible toxic agents, psychosocial condition and review of symptoms. The provider will specifically inquire about the symptoms listed on the CCEP Provider-Administered Patient Questionnaire. A comprehensive medical evaluation, with focused attention to the patients' symptoms and health concerns, should be conducted.

Individuals who, after completing MTF Phase I evaluations, do not have a clearly defined diagnosis which explains their symptoms should be reviewed by the CCEP-designated physician for further evaluation and consultations needed and/or for referral to the RMC.

Phase II level evaluations are performed only after complete clinically indicated evaluations (including appropriate specialty consultations) are conducted at the MTF and the RMC.

CBC

U/A

SMA-12

Phase II evaluations consist of the following laboratory tests, consultations, and as necessary, symptom-specific examinations. Elements of the Phase II evaluation may be accomplished by the local MTF as needed in the comprehensive evaluation of the Phase I patient in order to obtain a definitive diagnosis.

CBC 

Sedimentation rate (ESR) 

C-Reactive protein 

Rheumatoid factor B12 and folate

ANA Thyroid function tests

Liver function

CPK

Urinalysis

TB skin test (PPD) with controls

Chest X-ray

Hepatitis serology

HIV testing

VDRL

B12 and folate

Thyroid function tests

(if not accomplished at MTF level)

Dental: Dental only if participant's annual screening not done

Infectious disease

Psychiatry: With physician-administered instruments:

Structured Clinical Interview for DSMIII-R

(SCID) (delete modules for mania and psychosis)

Clinician-Administered PTSD Scale (CAPS)

Neuropsychological Testing: Only as indicated by psychiatry consult

The RMC CCEP physician ensures that Phase II patients with the following undiagnosed symptoms receive the tests and consultations listed below.