PTSD Evaluation with PCL Clinical Reminder

September 2009

PTSD Outcome Measure

• Requested by Secretary Shinseki, to be implemented at beginning of FY10

• Initial target population: OEF/OIF Veterans in active treatment for PTSD

• Requirement: evaluation with PCL-C at initiation of treatment, and every 90 days for duration of treatment

Definitions for PTSD Outcome Measure

• OEF/OIF Veteran—identified by markers in record, usually completed at registration, or through required OEF/OIF screening for Veterans discharged post 9/2001.

• PTSD: Primary diagnosis 309.81• Active Treatment: two or more visits in past

120 days, in clinic with primary MH stop code (exclude PC-MH Integration, psychological testing, and vocational clinic stops)

Resolving or Meeting the Measure

• Administration of PCL-C; due every 90 days during course of treatment– Initial implementation will be with the PCL-C. The

PCL-S (trauma specified) is recommended, and the reminder will be updated to change to PCL-S once the instrument is available in MHA software

• Completion of question regarding impact of symptoms on functioning

• BOTH ARE REQUIRED!

To Access Clinical Reminder

• Start a New Progress Note• Click on Reminder Drawer• Select “PCL Needed for PTSD” from reminder

list

Displays prior administrations of PTSD related assessments

Because the PCL-S is not available in MHA yet, the initial clinical reminder will use the PCL-C and an additional question regarding the specification of the trauma. This item is worded the same as what is in the PCL-S. Adding the PCL-S to the MHA package has been requested.

Clicking on the Perform PCL-C button will bring up the test form for the PCL-C. Complete the assessment, and click the Done button. When the clinical reminder is finished, the test results will pass to the MHA files in VistA.

This question assesses impact on functioning; it is the same as the functional impact item on the PHQ-9. Completion of both the PCL-C and this question are necessary to resolve the reminder

Options are included to provide documentation of being unable to complete evaluation. Severe cognitive impairment will remove the individual from cohort requiring evaluation. Acute illness or refusals can be documented, but the evaluation will remain a requirement for those individuals.

Indicating that the individual is no longer in active treatment for PTSD will pass a health factor that will remove the Veteran from the patient cohort. If there are two visits in MH stop codes and two diagnoses of PTSD within 120 days of each other subsequent to the documentation of no longer in active treatment, the reminder will again become due for the Veteran.

Progress note contains assessment items—added disclaimer to address limitations of self report data

Status of Reminder now Resolved, due again in 90 days

Visits that make reminder due displayed

Qualifying diagnoses and associated visits displayed

Resolution—PCL-C and Health Factor displayed