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CREW v. Army: Re: PTSD Diagnoses: 12/12/08 - PTSD Documentation

CREW v. Army: Re: PTSD Diagnoses: 12/12/08 - PTSD Documentation

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Published by CREW
On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.
On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.

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Published by: CREW on Mar 31, 2011
Copyright:Public Domain

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04/06/2012

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From:VA DIRECTOR'S
OFFICE
3193397135
09/19/2008
09
16
#090
P.001/052
VHA FAX
TRANSMITTAL
~
 
Department
of
Veterans Affairs
ToFax Number
r
FTS
r
Commercial
Dale No.
PagesAttached
Acting
VHA
FOIA
Officer
(19F2)
(215)
823-5274
09/19/2008
51
Subject
FOIA
LITIGATION:
CitizensforResponsibility
and
Ethicsin
Washington,
v.
VA
FromTelephone Number Commercial
Amber
Smith,
FOJA
Officer
Iowa
City
Iowa
(319)
530-7694
This transmission
is
intended only for
the
use of
the
person
or
office to whom it
is
addressed
and
may
contain
information
that
is
privileged. confidential,
or
protected
by law.
All
others
lire hereby notified
that
receipt
of
this message does not waive
any
applicable privilege
or
exemption fromdisclosure
andthat
any dissemination,
distribution,
or
copying
of
this communication is prohibited.
If
you received this communication in
error,
please notify us immediately at
the
telephone
number
shown below.
Thank
you.
Tim,
This
is
the
documentation
given
to
me
by
our
medical
center
manager/leadership.
Please
let
me
know
if
you
have
any
questionsor
need
anything
else.
Thanks
Amber
VA FORM
10-o114R
SEP 1997
 
From:VADIRECTOR'SOFFICE
3193397135
09/19/2008
09 16
#090
P.002/052
INITIAL
EVALUATIONFOR
POST-TRAUMATIC
STRESS
DISORDER
EXAMINATION
Name:
SSN:
Date
of
Exam:C-number:Place
of
Exam:
A.
Identifying Information:
• age• ethnic background• era
of
military
service• reason
for
referral (original
exam
to
establish
PTSO
diagnosis and related psychosocial
impairment; re-evaluation
of
status
of
existing service-connected
PTSO
condition)
B.
Sources
of
Information:
• records reviewed (C-file,
00-214,
medical records,
other
documentation)
• review
of
social-industrial
survey
completed by social
worker
•
statements
from
collaterals•
administration
of
psychometric
tests and questionnaires
(identify
here)
C.
Review
of
Medical Records:
1.
Past Medical
History:
a.
Previous hospitalizations and
outpatient
care.b.Complete medical
history
is required, including
history
since discharge
from military
service.
c.
Review
of
Claims Folder is required on initial exams
to
establish
or
rule
out
the
diagnosis.2. Present Medical
History
-
overthe
past one year,a. Frequency,
severity
and
duration of
medical and psychiatric
symptoms.
b. Length
of
remissions,
to
include capacity
for
adjustment
during
periods
of
remissions.
 
From:VA DIRECTOR'S OFFICE
3193397135
09/19/2008
09
17
#090
P.003/052
D.
Examination
(Objective
Findings):
Address each
of
the
following and fully describe:
History (SubjectiveComplaints):
Comment on:Premilitary History
(refer
to
social-industrial survey
if
completed)
• describe
family structure
and
environment
where raised
(identify
constellation
of family
members and
quality of
relationships)•
quality
of
peer relationships and social
adjustment
(e.g., activities, achievements,
athleticand/or extracurricular involvement,
sexual involvements, etc.)• 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
developmentalmilestones (performance
in
employment or
schooling, routine responsibilities
of
self-care,
family
role functioning, physical health, social/interpersonal relationships, recreation/leisurepursuits).Military History• branch
of
service (enlisted
or drafted)
• dates
of
service• dates and location
of
war
zone
duty
and
number
of
months
stationed in war zone• Military Occupational Specialty (describe nature and duration of Jobes) in
war
zone)• highest rank obtained during service
(rankat
discharge if
different)
•
type of
discharge from
military
• substance use and consequences
of
substance use• describe routine
combat
stressors veterans was exposed to
(refer
to Combat Scale)• combat wounds sustained (describe)
•
clearly
describe specific stressor
event(s)
veteran
considered
particularly
traumatic,particularly, if the
stressor is a type
of
personal assaUlt, including sexual assaUlt,provide
information,with
examples,
if
possible.• indicate overall level
of
traumatic
stress exposure (high, moderate,
low)
based on frequencyand severity
of
incident exposure• citations
or
medals received• disciplinary infractions
or
other adjustment
problems during
military

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