PTSD Compensation and Military Service (2007) / Chapter Skim
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Appendix C Automated Medical Information Exchange (AMIE) Worksheets for Initial and Review Examinations for PTSD
Appendix C Automated Medical Information Exchange (AMIE) Worksheets for Initial and Review Examinations for PTSD
Pages 221-237
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From page 221... ...
What follows are reproduced verbatim from the most current PTSD initial and review evaluation worksheets posted to the VA website (http:// www.vba.va.gov/bln/21/Benefits/exams/index.htm) at the time this report was completed.
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From page 222... ...
a board-certified or board "eligible" psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist a psychiatry resident under close supervision of a board certified or board eligible psychiatrist or licensed doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist.
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From page 223... ...
• education obtained and performance in school • employment • legal infractions • delinquency or behavior conduct disturbances • substance use patterns • significant medical problems and treatments obtained • family psychiatric history • exposure to traumatic stressors (see CAPS trauma assessment checklist) • summary assessment of psychosocial adjustment and progression through developmental milestones (performance in employment or schooling, routine responsibilities of self-care, family role function ing, physical health, social/interpersonal relationships, recreation/ leisure pursuits)
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From page 224... ...
based on frequency and severity of incident exposure • citations or medals received • disciplinary infractions or other adjustment problems during military NOTE: Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor.
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From page 225... ...
• treatment history for significant medical conditions, including hospitalizations • history of inpatient and/or outpatient psychiatric care (dates and conditions treated) • history of assaultiveness • history of suicide attempts • summary statement of current psychosocial functional status (per formance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interper sonal relationships, recreation/leisure pursuits)
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From page 226... ...
Psychometric Testing Results • provide psychological testing if deemed necessary • provide specific evaluation information required by the rating board or on a BVA Remand. • comment on validity of psychological test results • provide scores for PTSD psychometric assessments administered • state whether PTSD psychometric measures are consistent or in consistent with a diagnosis of PTSD, based on normative data and established "cutting scores" (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL ≥ 50; Mis sissippi Scale ≥ 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-8)
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From page 227... ...
A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed.
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From page 228... ...
M Integrated Summary and Conclusions • Describe changes in psychosocial functional status and quality of life following trauma exposure (performance in employment or schooling, routine responsibilities of self care, family role function ing, physical health, social/interpersonal relationships, recreation/ leisure pursuits)
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OR • There is occasional decrease in work efficiency or there are inter mittent periods of inability to perform occupational tasks due to signs and symptoms, but generally satisfactory functioning (routine behavior, self-care, and conversation normal)
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• PTSD symptoms are not severe enough to require continuous medication. Include your name; your credentials (i.e., a board certified psychia trist, a licensed psychologist, a psychiatry resident or a psychology intern)
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From page 231... ...
a board-certified psychiatrist or board "eligible" psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate level psychologist; a psychiatry resident under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist; a clinical or counseling psychologist completing a one year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist; a licensed clinical social worker (LCSW)
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From page 232... ...
• history of violence / assaultiveness • history of suicide attempts • summary statement of current psychosocial functional status (per formance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interper sonal relationships, recreation/leisure pursuits)
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From page 233... ...
Psychometric Testing Results • provide psychological testing if deemed necessary provide specific evaluation information required by the rating board or on a BVA Remand. • comment on validity of psychological test results · provide scores for PTSD psychometric assessments administered • state whether PTSD psychometric measures are consistent or in consistent with a diagnosis of PTSD, based on normative data and established "cutting scores" (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL ≥ 50; Mis sissippi Scale ≥ 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-8)
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From page 234... ...
A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed.
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From page 235... ...
K Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand (i.e., furnish the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken)
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OR • There are PTSD signs and symptoms that are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. Provide examples and pertinent symptoms, including those already reported.
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From page 237... ...
APPENDIX C Include your name; your credentials, i.e., a board certified psychiatrist, a licensed psychologist, a psychiatry resident or a psychology intern, LCSW, or NP and circumstances under which you performed the examination, if applicable, i.e., under the close supervision of an attending psychiatrist or psychologist; include name of supervising psychiatrist or psychologist. Signature: Date: Signature of Supervising Date: psychiatrist or psychologist: SOURCE: http://www.vba.va.gov/bln/21/Benefits/exams/disexm56.htm.
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