Documentation support for VA C&P exams, DBQs and IMOs
Conduct the examination your way. My Clinical Writer turns your interview or notes into a structured draft that follows the template you set up for the DBQ, independent medical opinion or nexus letter, and you add the medical opinion.
Free trial, no credit card required.
For VA examiners and independent evaluators
Mental health disability evaluations for veterans are long, structured documents. A compensation and pension (C&P) examination or a Disability Benefits Questionnaire (DBQ) has to cover service history, current symptoms, functional impairment and diagnosis in the order the form expects, and an independent medical opinion has to state a clear opinion with a supporting rationale. Whether you are a contract examiner, an independent medical evaluator or a private practitioner completing DBQs, My Clinical Writer takes on the first draft so you can concentrate on the examination and the opinion.
How it works
Record the veteran interview
Conduct the examination naturally and cover what the DBQ requires: pre-military, military and post-military history, the claimed conditions, current symptoms, their severity and frequency, and occupational and social functioning. The AI transcribes the interview and organizes it into the sections of your template.
Or type your findings
Enter demographics, service history, claimed conditions and symptoms as notes, or upload records you have reviewed. The AI turns them into a structured draft.
Add your opinion and finalize
Check that every required field is complete, write or refine your medical opinion and rationale, make sure the functional impairment description matches your findings, and note any secondary conditions or aggravation. Then copy the document out or save it as a Word file.
Set up your template
Mirror the DBQ, IMO or nexus letter structure you use.
Examine
Record the interview or type your findings and record review.
Get a draft
The AI organizes your findings into the template's sections.
Add your opinion
You write the opinion and rationale, review, and sign.
What a mental health DBQ usually needs
- Diagnosis. Current DSM-5 diagnoses, with the criteria you found met, for conditions such as PTSD, major depressive disorder, anxiety disorders, bipolar disorder, adjustment disorders and OCD.
- History. Relevant pre-military, military and post-military history, including stressors for a PTSD claim.
- Symptoms. The symptoms present, with severity and frequency.
- Occupational and social impairment. A description of functioning that matches the levels the VA rating schedule uses for mental disorders.
- Opinion and rationale. Where an opinion is requested, a clear statement using the VA standard, such as whether a condition is at least as likely as not related to service, with your reasoning.
- Secondary conditions and aggravation. Documented where relevant.
Your template can hold reminders for each of these, so the draft prompts you for anything missing. For civilian assessments, see our psychiatric evaluation template page.
Serve those who served
Veterans deserve thorough and accurate evaluations. Less time spent formatting means more attention for the examination itself and for a well-reasoned opinion.
The AI drafts. You decide.
My Clinical Writer writes a first draft from what you record, type or upload. You review it, edit anything that does not match your clinical judgment, and only then sign or export it. The assessment, the diagnosis and the plan are always yours, and you remain responsible for the final record.
Patient data is protected as described on our security and HIPAA page: 256-bit encryption in transit and at rest, role-based access, audit trails, and a Business Associate Agreement that every account accepts at registration.
Questions, answered.
Does this replace my clinical judgment?
No. It is a documentation tool that transcribes, organizes and formats your interview and findings. The diagnosis, the functional impairment assessment and any medical opinion on service connection are entirely yours, and you review every line before you sign.
Can I use it for independent medical opinions and nexus letters?
Yes. Independent evaluators can set up templates for IMOs, IMEs and nexus letters. The AI drafts from your findings and rationale; it does not form an opinion. Whether a condition is at least as likely as not related to service is your determination, based on your examination and review of the records.
Does it include the official DBQ forms?
You build a template that mirrors the sections of the DBQ you complete, using the current form from the VA as your reference. The AI then drafts into those sections. Always check the finished document against the current official form and instructions.
Can I document in-service stressors for a PTSD evaluation?
Yes. Add a section for in-service stressors to your template, whether combat-related, military sexual trauma, fear of hostile military or terrorist activity, or personal assault, and the AI will organize what you describe there.
Does it work for both initial and review examinations?
Yes. Keep separate templates for initial examinations, which need the full history, and review examinations, which focus on changes since the last exam.
Is veteran health information protected?
My Clinical Writer is HIPAA compliant, with 256-bit encryption in transit and at rest, access controls and audit trails, and every account accepts our Business Associate Agreement at registration. See the security page.
Try it on your next note.
Start with the free trial, no credit card required. Upgrade whenever you are ready.