C & P Examination Interview Sheet

C & P Interview Sheet for PTSD



Date of Exam:


Place of Exam:

Narrative: Service-connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the extreme traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. It is the responsibility of the rating specialist to confirm that the cited stressor occurred during active duty.

A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means the initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.

A. Review of Medical Records

B. Medical History (Subjective Complaints):

Comment on:

1.Past Medical History:

a .Previous hospitalizations and outpatient care.

b. Medical and occupational history (the time between last rating examination and the present need be accounted for, UNLESS the purpose of this examination is to ESTABLISH service connection, then complete medical history including description of stressors and history since discharge from military service is required.

c. Review of Claims Folder is also required on initial exams to establish or rule out the diagnosis.

2.Present Medical, Occupational and Social History - over the past one-year.

a. Frequency, severity and duration of psychiatric symptoms.

b. Length of remissions, to include capacity for adjustment during periods of remissions.

c. Extent of social impairment and time lost from work over the past 12-month period. If employed, identify current occupation and length of time at this job. If unemployed, note in complaints whether veteran contends it is due to the effects of a mental disorder. Further discuss in DIAGNOSIS what factors, and objective findings support or rebut that contention.

3.Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1.Stressor information: Clearly describe the stressor. Particularly if the stressor is a type of personal assault, including sexual assault, provide information, with examples, if possible, of behavioral, cognitive, social, or affective changes that the veteran links to the stressor. Include information on related somatic symptoms. If there is a history of multiple stressors, assess the impact of each, to the extent possible.

2.Mental status exam to confirm or establish diagnosis in accordance with DSM-IV:

a. Are all diagnostic criteria to establish a diagnosis for 309.81 Post-traumatic Stress Disorder, as specified in DSM-IV, fully met?

b. For initial examination to establish service-connection fully discuss the criteria in steps A through F supporting or ruling out the diagnosis.

c. Describe any associated symptoms.

d. Specify onset and duration of symptoms as acute, chronic, or with delayed onset.

3.Describe in detail the linkage between the stressor and the current symptoms and clinical findings.

4.Describe and fully explain the existence, frequency, and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

a. Impairment of thought process or communication.

b. Delusions, hallucinations and their persistence.

c. Inappropriate behavior cited with examples.

d. Suicidal or homicidal thoughts, ideations or plans or intent.

e. Ability to maintain minimal personal hygiene and other basic activities of daily living.

f. Orientations to person, place, and time.

g. Memory loss, or impairment (both short and long-term).

h. .Obsessive or ritualistic behavior, which interferes with routine activities and describe any found.

i. Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent.

j. Panic attacks noting the severity, duration, frequency, and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation is shown.

k. Depression, depressed mood or anxiety.

l. .Impaired impulse control and its effect on motivation or mood.

m. Sleep impairment and describe extent it interferes with daytime activities.

n. Other symptoms and the extent they interfere with activities.

D. Diagnostic Tests:

1.Provide psychological testing if deemed necessary.

2.If testing is requested, the results must be reported and considered in arriving at the diagnosis.

3.Provide specific evaluation information required by the rating board or on a BVA Remand.

a. Competency: State whether the veteran is capable of managing his or her benefit payments in the individual's own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs.)

b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing please state why. If the requested opinion cannot be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks, " . . .is it at least as likely as notů" fully explain the clinical findings and rationale for the opinion.

4.Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:


1.The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.

2.If the diagnosis is changed, explain fully whether the new diagnosis represents a progression of the prior diagnosis or development of a new or separate condition.

3.If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.

4. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

Note: VA is prohibited by statute from paying compensation for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on direct service connection, secondary service connection, or aggravation by a service-connected condition. Therefore, when alcohol or drug abuse accompanies or is associated with another mental disorder, separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects, state why.

F. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning over the past year, etc.

If multiple Axis I or Axis II diagnoses exist, attempt to the extent possible, to provide a GAF score for the service connected conditions alone as well as a separate overall GAF score based on all mental disorders present, and explain and discuss your rationale. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.) If it is not possible to separate the symptomatology, explain why.

Writers note: The GAF is a numerically based subjective evaluation done by qualified medical personnel. A low percentage, of say 30%, means you are almost a basket case.

DSM-IV is only for application from 11/7/96 on. Therefore, when applicable not whether the diagnosis of PTSD was supportable under DSM-III-R prior to that date. The prior criteria under DSM-III-R are provided as attachment.





Writers note - Both of the above documents are available on the Internet, by the VA, or one of the Service Organizations. The are public knowledge.

E-MAIL Bub Parrish at iparrish@ptsdmanual.com
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