NEVADA DIVISION OF INDUSTRIAL RELATIONS Workers' Compensation Section PERMANENT WORK-RELATED MENTAL IMPAIRMENT RATING REPORT WORK SHEET Since the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, does not provide a quantified method for assigning permanent impairment percentages under Chapter 14, "Mental and Behavioral Disorders," the provider shall use this form when evaluating claims accepted pursuant to NRS 616C.180. Patient Name: Claim No.: Date of Service: Insurer: SCORING INSTRUCTIONS: 1. This form should only be used to determine an impairment after the case has been found to meet all of the specific criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. (DSM-IV) diagnosis. The AMA Guides to Permanent Impairment, 5th Edition should be consulted for guidance in determining these ratings. Determination of a rating of permanent mental or behavioral impairment shall be limited to mental or behavioral disorder impairments not likely to remit with further mental health treatment. Impairment ratings based on chronic pain are not applicable within the mental/behavioral domain. To obtain the final overall impairment rating: a. The elements to be rated are divided into four Areas of Function: Activities of Daily Living; Social Functioning; Thinking, Concentration and Judgment; and Adaptation to Stress. 2. 3. 4. 5. b. Assign a rating (0-6) to each subcategory of the areas of function based on patient self-report, other sources of information, and the physician's clinical assessment. (See Category Definitions on Page 5 of this form.) Given the heavy reliance on the patient's subjective report for information in some of the ratings, the physician should give careful consideration to any corroborating evidence that might be available. c. Average the two highest subcategory ratings within each Area of Function to obtain the overall category rating. For example, if the two highest scores are 2 and 5, the category score is 3.5. d. To calculate the overall impairment rating, average the two highest category ratings and then, if appropriate in the case, use clinical judgment to add or subtract up to 0.5 point from the result. If the score is modified in this fashion due to clinical judgment, justification for doing so must be documented. Factors influencing the physician's discretion may include the following: i. Factors influencing the patient's believability, such as the presence of symptom magnification, or the presence or absence of corroborating information from psychological or neuropsychological testing; ii. e. 6. The extent to which medication ameliorates the effects of the condition; Use the Category Conversion Table in these instructions to convert the final number to a percentage. Include the DSM-IV diagnosis at the top of the worksheet. 1 D-9c (rev. 6/10) American LegalNet, Inc. www.FormsWorkFlow.com The final determination must include ratings for all of the elements in each area of function, the category averages reached in each area of function, the overall average, the final assigned overall permanent impairment rating, and documentation for any divergence (± 0.5) from the calculated score. CATEGORY CONVERSION TABLE Final Score Percentage 0 0 0.25 0 0.5 1 0.75 1 1 1 1.25 2 1.5 3 to 4 1.75 5 2 6 to 7 2.25 8 to 9 2.5 10 to 12 2.75 13 to 15 3 16 to 18 3.25 19 to 21 3.5 22 to 23 3.75 24 to 25 4 26 to 32 4.25 33 to 38 4.5 39 to 44 4.75 45 to 50 5 51 to 56 5.25 57 to 62 5.5 63 to 68 5.75 69 to 75 6 76 to 83 6.25 84 to 91 6.5 92 to 100 7. If apportionment is applicable, complete a separate form calculating the pre-injury rating to be subtracted from the total current rating. 8. If there is a finding of no impairment, refer to Part V on the worksheet, if appropriate. 2 D-9c (rev. 6/10) American LegalNet, Inc. www.FormsWorkFlow.com WORKSHEET Patient Name Claim # Date of Service: Insurer NOTE: Determination of a rating of permanent mental or behavioral impairment shall be limited to mental or behavioral disorder impairments not likely to remit with further mental health treatment. Further, impairment ratings based on chronic pain are not applicable within the mental/behavioral domain, but are restricted to physical examination with evidence of anatomic or physiologic correlation and included within a physical impairment rating. I. DSM-IV Diagnosis: Axis I: Axis III: Axis V: Axis II: Axis IV: II. LEVELS OF PERMANENT MENTAL IMPAIRMENT Category 0. No permanent impairment 1. Minimal Category of Permanent Impairment 2. Mild Category of Permanent Impairment 3. Moderate Category of Permanent Impairment 4. Marked Category of Permanent Impairment 5. Extreme Category of Permanent Impairment 6. Maximum Category of Permanent Impairment III. AREAS OF FUNCTION1 Rate only impairments due strictly to the psychiatric condition. 1. Activities of Daily Living, see 14.3a, p. 361 of Guides, 5th ed. and Table 1-2, p. 4 (Guides, 5th ed.) 0123456 0123456 0123456 0123456 0123456 0123456 Self-care, personal hygiene (urinating, defecating, brushing teeth, combing hair, bathing, dressing oneself, eating) Communication (writing, typing, seeing, hearing, speaking) Physical activity (standing, sitting, reclining, walking, climbing stairs) Sensory function (hearing, seeing, tactile feeling, tasting, smelling) NB: smell/taste 1%-5% WP, p. 262 Nonspecialized hand activities (grasping, lifting, tactile discrimination) Travel (driving, riding, flying) i.e. impairments in driving, riding, flying which are generally a result of symptoms of affective or Overall Category Rating: (average of 2 highest) anxiety disorders Sexual function (orgasm, ejaculation, lubrication, erection) Sleep (restful, nocturnal sleep pattern) 0123 0123456 2. Social Functioning see 14.3b, p. 362 of Guides, 5th ed. 0123456 0123456 0123456 0123456 Interpersonal relationships Communicates effectively with others Participation in recreational activities (consider pre-injury activities of the patient) Manage conflicts with others--negotiate, compromise Overall Category Rating: (average of 2 highest) 1 See attached Appendix for further description of all or part of the listed areas of function. 3 D-9c (rev. 6/10) American LegalNet, Inc. www.FormsWorkFlow.com 3. Concentration, Persistence, and Pace see 14.3c, p. 362 of Guides, 5th ed. 0123456 0123456 0123456 0123456 0123456 0123456 0123456 0123456 Ability to perform complex or varied tasks Judgment Problem solving Ability to abstract or understand concepts Me