Muscles or Nerves?
Cannot be a standalone diagnosis.
What it Radiculopathy?
A surgical procedure is noted, no scar DBQ found in DBQ/DT/MO tab. No scar is reported. These are options.
Provide an explanation in REMARKS/EXTRA REMARKS to explain no scar is visible.
This is a must when a joint is busted.
What is imaging/diagnostics?
Diagnostic results should always come from this place.
This statement is required for an ESR requested medical opinion when no diagnosis is rendered.
What is "No diagnosis was rendered therefore no medical opinion is warranted." ?
This DBQ covers SC radiculopathy when the VA wants it.
What is the Peripheral Nerve (PN) DBQ?
Abnormal findings documented in 3C (RUOT) and/or 3D (Flare-ups) only. What is the diagnosis?
No diagnosis. For all ROUT/Flare-up sections on MUSC DBQS, 3C and 3D are subjective findings: meaning abnormal findings indicated in 3C and/or 3D would not warrant a diagnosis if these are the ONLY abnormal findings in Section III.
Examiners do this when a veteran presents medical records at time of exam.
What is Reviews records, summarizes in Evidence Review section and select "Other". Add statement records were brought in, reviewed, and veteran was instructed to present records to VA for uploading.
There are 4 exceptions for a required DT to not be completed. You can identify 2.
What are 1) not medically advisable 2) Declined by veteran 3) Veteran was a no show 4) VA declined to approve requested invasive procedure. (name at least 2)
These three components create a solid direct service connection.
What is evidence of an injury/exposure/disease/event during service period, evidence of a current disability/illness/condition caused by injury/event/exposure/disease occurring during service period, and a nexus between the current disability and the in-service event?
Carpel Tunnel Syndrome must be evaluated on this DBQ while cross-referenced with that DBQ.
PN and Hand or wrist or shoulder/Arm.
A diagnosis of instability includes this.
Objective evidence on exam to support the diagnosis. Cannot be subjective reporting only.
These are new, but now a normal addition to the MUSC DBQs.
What are the Musculoskeletal Supplemental Questions?
This phrase tells us a diagnostic is the examiner's discretion
What is 'clinically indicated'?
An ESR request for a COMBAT Medical Opinion should be found here.
What is Section III of the Medical Opinion?
Veteran is diagnosed with IVDS, cubital tunnel syndrome, and Left Lower Extremity radiculopathy for a new claim. Complete the PN and Back DBQ.
Complete PN for Cubital Tunnel Syndrome. Back DBQ complete for IVDS and LLE Radiculopathy. Cross-reference as required.
A surgical procedure is required to be diagnosed if it is here.
Specifically listed on the DBQ guide. All other's not listed on the guide are diagnosed based on examiner's discretion.
A resolved, newly claimed condition should be diagnosed at this time.
What is when the particular DBQ allows for current and past diagnoses to be rendered. (Same is true for SC conditions).
This is the standard age for diagnostic testing.
What is no older than 12 months?
This is the response provided when the VA requests multiple opinions for the same contention.
What is "all contentions must be addressed' and if a positive opinion is provided for one requested medical opinion, additional opinions are not required but should have a statement to indicate a positive opinion has been provided?
Cross-reference these for Muscle Strength testing.
What are MS, CNS, Back, Neck, PN/DPN and Hand?
Veteran reports subjectively, instability. No objective evidence found on exam. This is what the examiner can do.
Acknowledge subjective report by selecting "yes" in Medical History for instability.
These 5 items do not belong in the functional impact statement.
What are 1. Current occupational status. 2. Workplace name
3. Title of position 4. Dates of employment
5. If veteran has to call out of work or leave work due to condition.
This is required as the gold standard for a diagnosis for all new claims, non-service connected types of disease.
What is a biopsy for benign and malignant cancers?
This should happen when the ESR includes a requested direct, secondary, or aggravated medical opinion, in conjunction with a Gulf War and/or TERA opinion.
What is "the examiner should address all medical opinions and state if a positive opinion was provided in a different section'?