Confirm the examination request
A compensation and pension examination supplies evidence for VA’s benefits decision. It is not a treatment visit. VA describes review examinations as assessing whether a condition’s severity has changed since the earlier examination. VA claim-exam guidance.
Read the actual request before choosing the record-review structure. An initial PTSD examination, a PTSD review, an examination for another mental disorder, and a requested medical opinion can involve different tasks. Do not assume that a generic mental health heading defines the assignment.
VA publishes a PTSD Review DBQ, while its public DBQ index lists Initial PTSD and Medical Opinion questionnaires as unavailable for public use. The public index is the starting point for locating the applicable form, rather than substituting one questionnaire for another. VA public DBQ index.
Confirm examiner qualifications and any assignment-specific requirements. The PTSD Review DBQ includes licensed doctorate-level psychologists among its eligible examiner categories and specifies conditions for other categories. Public availability of a form alone does not establish authorization for a particular examination. PTSD Review DBQ, introductory instructions.
Inventory the supplied records
Build an inventory before relying on a summary. Include document type, author, document date, period discussed, physical PDF pages, and whether the source is complete. Distinguish the packet you received from the larger record that may exist elsewhere.
Start with the examination request and prior evaluation, then identify treatment notes, medication records, measurement reports, relevant medical records, statements, and workplace material. Record missing attachments explicitly. A summary of a test result is different from the completed response sheet; a reference to counseling is different from having those counseling notes.
In our fictional packet, the referral describes an established service connection, but the underlying decision is unavailable. The source summary should preserve that distinction.
Establish the prior evaluation as a dated baseline
Extract what the earlier examiner actually documented: historical diagnosis, reported symptoms, observed behavior, and described functioning. Preserve the evaluation date and any limitations of the supplied excerpt.
Use that material to organize questions about change. Do not carry a historical diagnosis or observation forward as if a current examiner had just established it. Keep later references to the earlier evaluation connected to their original source.
Follow the interval history
Organize treatment and reported response chronologically. Capture attendance when documented, medication regimens and changes, reported adherence, tolerability, and the time periods attached to symptom descriptions.
Avoid assigning the cause of improvement simply because treatment preceded it. Medication, psychotherapy, work arrangements, physical health, and other circumstances may change during the same interval. Preserve the source author’s attribution and any uncertainty.
For overlapping complaints such as sleep disturbance, pain, fatigue, and low mood, record what each source says without assigning every symptom to one diagnosis. Identify questions for the current assessment instead of filling gaps with a new diagnosis.
Keep observations and accounts distinct
Label information as examiner observation, veteran report, collateral report, employer account, or historical material. Note what the speaker could actually observe and the dates covered.
Check copied text before counting repeated statements as corroboration. Separate the date a note was written from the date of an event or quotation inside it. A difference in setting or observation window may explain accounts that initially look inconsistent.
When an unresolved disagreement remains, identify it neutrally with references to both sources. Source organization does not establish credibility.
Preserve the limits of screening and measurement
For each reported score, retain the instrument, score date, recording date when different, source page, and whether administration details and response sheets are available.
The PCL-5 supports uses including symptom monitoring, screening, and provisional diagnosis; a structured clinical interview is the diagnostic gold standard described by VA’s National Center for PTSD. A total reproduced in a later note is not a newly administered assessment. VA PCL-5 guidance.
Do not translate a screening total into a disability percentage or infer validity findings that the source does not report.
Prepare an examination working file
The PTSD Review DBQ addresses evidence reviewed, relevant interval history, diagnoses and differentiation, symptoms, occupational and social impairment, and other examination judgments. Use the current form and actual request to identify the topics the examiner must address. Official PTSD Review DBQ.
An organized working file can contain:
- A record inventory and dated chronology.
- A prior-evaluation summary with source pages.
- Interval treatment and functional evidence, with speaker attribution.
- Repeated or conflicting material that needs clarification.
- Missing records and questions for the current interview.
Do not preselect examination conclusions from the historical packet. Current findings, diagnostic reasoning, differentiation of overlapping symptoms, and any requested opinions require the examiner’s assessment. VA makes the benefits determination. VA claim-exam guidance.
Check the source before using the summary
PsyReview organizes supplied records into chronology and topic-based evidence with PDF references. Open the original pages behind material entries. Verify dates, attribution, qualifiers, and missing-information statements before using the output in your evaluation work.
Try the fictional VA PTSD review case, or keep the record-review checklist beside your next packet.
Start a free trial — no credit card required
Official sources reviewed October 31, 2026. The workflow suggestions are PsyReview editorial guidance; the linked VA materials and applicable examination request govern the actual assignment.