Download Standard Diagnostic Assessment (DA) Tool

05/2016V1
Standard Diagnostic Assessment Tool
Approved for use with South Country Members
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
Date of Interview:
Member Demographics
Member Name:
Member PMI:
Member DOB/Age:
Member Address:
Member City, State, Zip:
List Mental Health Diagnosis with ICD 10 Code:
1.
2.
3.
4.
5.
(Please attach WHODAS 2.0 or include version used and score)
Presenting Symptoms
Anxious
Guilty feelings
Weight loss
Sexual issues
Ashamed
Heavy feeling
Difficulty breathing
Sleep problems
Unable to enjoy self
Hopelessness
Dizziness
Wound up
Depressed/Sad
Irritable/angry/lose temper
Headaches
Discomfort
Elevated mood
Loneliness
Heart racing
Isolative
Excessive Worry
Low self-esteem
Increased appetite
Withdrawn
Feel inferior
Paranoia
Weight gain
Auditory hallucinations
Feel unworthy
Tense feelings
Low energy/tired
Distressing memories
Feel numb
Aches/pain
Night terrors
Disturbing thoughts
Frequent mood swings
Decreased appetite
Numbness/tingling
Delusions
Poor concentration
Racing thoughts
Visual hallucinations
Thoughts/urges of self-harm
Cry easily/often
Impulsive
Wants to die
Wants to harm others
Lack motivation
Reactive
Repetitive actions
Restless/fidgety
Shaking
Violent
Actions of self-harm
Reason for referral:
Member’s perception of his/her condition:
Duration of symptoms:
Potential consequences of symptoms:
Contributing contextual non-personal factors:
Cultural Influences and Client Impact:
Prognosis:
Current Life Situation
Current living situation:
Current Financial Status:
Highest Education Level Completed:
Employment Status:
Current Relationship Status:
Children/Step Children?
Primary Care Physician:
YES
NO
If yes, how many?
Primary Care Clinic:
Ages?
Page 1 of 5 pages
05/2016V1
Standard Diagnostic Assessment Tool
Approved for use with South Country Members
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
Any known allergies?
YES
Current Medication
NO
Dose
1.
2.
3.
4.
5.
6.
7.
8.
If yes, please list:
Start Date
Current
Medication
Dose
Start Date
9.
10.
11.
12.
13.
14.
15
16.
Relevant History
Records Review:
Mental Health Treatment History:
Developmental History:
Maltreatment or Abuse History:
History of Drug/Alcohol Abuse:
Legal History:
Health History and Concerns:
Family History of Mental Illness and/or Substance Use Disorders:
Would you like services specific to language, age, gender, culture, religious preference, race, ethnicity, sexual orientation or disability?
YES
NO
If yes, please specify:
Functional Impairment
Coping Skills
Ability to Care for Self
Daily Living Skills
Medical/Dental
Mental Health Services
Financial Management
Use of drugs/alcohol
Housing/Shelter
Education/School
Transportation
Employment
Danger to Self and/or Others
Social
Legal
Interpersonal/Relationship and Environment
Other:
Strengths and Resources; include extent and quality of social networks:
Page 2 of 5 pages
Standard Diagnostic Assessment Tool
05/2016V1
Approved for use with South Country Members
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
How does diagnosis interact with/impact member’s life?
Describe how diagnosis criteria is met, duration of symptoms and functional impairment:
Clinically Appropriate Services Needed
Dialectical Behavior Therapy (DBT)
MI/CD Groups / Treatment
Psychotherapy
County Case Management
Assertive Community Treatment (ACT)
Health Education/Medication Management/ Nursing
Transportation Services
Services
Intensive Residential Treatment (IRTS)
Housing Supports
Adult Rehabilitative Mental Health Services (ARMHS) -if this
Psychiatry/Medication Management
is recommended, please select areas of skills which should be
CPS Services
addressed below:
Crisis Services
Communication Skills
Budgeting/Financial
Community Integration
Independent Living Skills
Community Support and Resources
Interpersonal Skills Training
Other Special Considerations
Identified Communication Needs:
Identified Barriers to Learning:
None Reported
None Reported
TDD/TTY Device
Learning Disability/Type
Language Interpreter Services needed
Inability to read and/or write
Other Spoken Language
Developmental Disability
Assisted Listening Device
Other:
Other:
Mental Status Exam
Appearance
Clean
Neat
Unkempt
Disheveled
Other:
Looks Stated Age
YES
NO
Older
Younger
Eye Contact
Appropriate
Inappropriate
Other:
Orientation
Memory
Attention
Perception
Motor Activity
Cognitive Performance
Thought Process
Danger to Others
Danger to Self
Fully Oriented
Time
Place
Person
Situation
Normal Limits
Deficient:
Immediate
Recent
Remote
Other:
Adequate
Inadequate
Other:
Adequate
Inadequate
Other:
Normal
Slowed
Restless
Agitated
Accelerated
Other
Normal limits
Poor memory
Low self-awareness
Short attention
Developmental disability
Poor concentration
Impaired judgement
Slow processing
Full Scale IQ is known:
Normal limits
Accelerated
Delusional
Paranoid
Ruminative
Intact
Grandiose
Tangential
Loose association
Slowed
Hallucination (visual, auditory, tactile)
Does not appear dangerous to others
Violent temper
Threatens others
Physical Abuse
Hostile
Assaultive
Homicidal ideation
Homicidal threats
Homicide attempt
Does not appear dangerous to self
Suicidal ideation
Recent attempt
Self-injurious/self-mutilation:
Hx of attempt:
Current plan/means:
Page 3 of 5 pages
Standard Diagnostic Assessment Tool
05/2016V1
Approved for use with South Country Members
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
Sensory Deficits
Speech
None
Speech
Hearing
Vision
Clear
Slurring
Slowed
Loud
Soft
Pressured
Minimal
Excessive
Incoherent
Delayed
Fast Other:
Mood
Euthymic
Unremarkable
Depressed
Tearful
Anxious
Manic
Labile
Other:
Affect
Normal
Blunted
Congruent
Euphoric
Incongruent
Flat
Expansive
Labile
Other:
Insight into Problem
Takes responsibility
Intellectual insight
Emotional insight
Slight awareness
Blames others
Complete denial
Judgement
Good
Fair
Poor
Impulse Control
Good
Fair
Poor
Attitude
Cooperative
Guarded
Withdrawn
Uncooperative
Oppositional
Belligerent /Hostile
Apathetic
Suspicious
Other:
Additional observations and others involved in assessment:
Narrative:
According to the Comprehensive Mental Health Act, the mental health professional conducting this diagnostic assessment must
complete the need for the following:
CAGE-AID
Completed
Score:
GAIN SS
Completed
Score:
PHQ-9
Completed
Score:
CASII (For Children Over 6)
Completed
Score:
ECSII (For Children Under 6)
Completed
Score:
LOCUS
Completed
Score:
Serious and Persistent Mental Illness Definition
“ A person with a serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the
following criteria:
(1) The adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;
(2) The adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months’ duration
within the preceding 12 months;
(3) The adult has been treated by a crisis team two or more times within the preceding 24 months;
(4) The adult (i) has a diagnosis of schizophrenia, bi-polar disorder, major depression, or borderline personality disorder; (ii)
indicates a significant impairment in functioning; AND (iii) has a written opinion from a mental health professional, in the last three
years, stating that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a
frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;
(5) The
adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s
commitment has been stayed or continued; or
(6) The adult (i) was eligible under clauses (1) to (5) but the specified time period has expired or the adult was eligible as a child
under section 245.4871, subdivision 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating
that the adult is reasonably likely to have future episodes requiring hospitalization or residential treatment, of a frequency described
in clause (1) or (2), unless ongoing case management or community support services are provided.
If #4 or #6 is selected, written opinion must be provided here:
Page 4 of 5 pages
Standard Diagnostic Assessment Tool
05/2016V1
Approved for use with South Country Members
South Country Health Alliance
2300 2300 Park Drive, Suite 100
Owatonna, MN 55060.
Phone (866) 722-7770
Fax (507) 431-6329
Severe Emotional Disturbance Definition
“ A person with a severe emotional disturbance” means a child who has an emotional disturbance and who meets one of the following
criteria:
(1) The child has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential
treatment for an emotional disturbance; or
(2) the child is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance
through the interstate compact; or
(3) the child has one of the following as determined by a mental health professional:
i. Psychosis or a clinical depression; or
ii. Risk of harming self or others as a result of an emotional disturbance; or
iii. Psychopathological symptoms as a result of being a victim of physical or sexual abuse or of psychic trauma within the past
year; or
(4) the child, as a result of an emotional disturbance, has significantly impaired home, school, or community functioning that has
lasted at least one year or that, in the written opinion of a mental health professional, presents substantial risk of lasting at least one
year.
If #4 is selected, written opinion must be provided here:
Clinician Information and Signature:
Mental Health Professional Signature:
Date:
Printed Name:
Agency Name and Address:
I am a qualified Mental Health Professional in the following field:
Psychiatric Nursing
Psychology (LP, LPP)
Clinical Social Work
Licensed Marriage & Family Therapy
Allied Field:
Psychiatry
Thank you!
Page 5 of 5 pages