A diagnostic assessment is a written report that documents clinical and functional face-to-face evaluation of a patients mental health, including the nature, severity and impact of behavioral difficulties, functional impairment, and subjective distress (stressors) effecting the patient, as well the assessment measures the patients strengths and resources. A diagnostic assessment is necessary to determine the individual’s need for mental health and/or substance abuse treatment/care. At our fous on the “Individual’s” needs, and during the assessment process develop a treatment plan that involves the patient’s imput with consideration of what may work for them. We pride ourself in focusing on the individual, and meeting their needs in a confidential and comfortable relaxing environment.
Conducted in the cultural context of the Client
- The current life situation including the following:
- Current living situation (including household membership and housing status)
- Basic needs status including economic status
- Education level and employment status
- Significant personal relationships (including evaluation of relationship quality)
- Strengths and resources (including extent and quality of social networks)
- Belief system
- Contextual non-personal factors contributing to the presenting concerns
- General physical health and relationship to patients culture
- Current medications
- The reason for the assessment, including the following:
- Perceptions of his/her condition ( Patient’s Voice is always heard at our facility)
- Description of symptoms (including reason for referral) or desire for treatment
- History of mental health treatment (including review of recipient’s records)
- Important developmental incidents
- Maltreatment, trauma, or abuse issues
- History of alcohol and drug usage and treatment
- Health history and family health history, including physical, chemical, and mental health history
- Cultural influences and their impact on the patient
- A mental status exam
- An assessment of needs based on baseline measurements, symptoms, behavior, skills, abilities, resources, vulnerabilities, and safety
- Screenings used to determine a client’s substance use, abuse, or dependency and other standardized screenings instruments reqiured by Palms Wellness for accuracy of care.
- Assessment methods and use of standardized assessment tools Clinical summary, recommendations, and prioritization of needed mental health, ancillary or other services
- Involvement of the patient’s family in assessment and service preferences and referrals to services on a “as need” (with consent only) basis
- Sufficient recipient data to support findings on all axes of the current edition of the Diagnostic and Statistical Manual (DSM), and any differential diagnosis.
We also assess any pending or current legal issues which may play a part in the patient’s needs and treatment plan of care.
Diagnostic Assessment Updates
An adult diagnostic assessment update can only be an update of a standard or extended diagnostic assessment. An adult diagnostic assessment update must be an update of a standard or extended diagnostic assessment that has occurred within the past 12 months; or an update of a standard or extended diagnostic assessment that has occurred within the past 24 months and an adult diagnostic assessment that has occurred within the past 12 months.
Our facility requires an assessment everyone 12 months unless the mental health status has changed. This allows us to measure progress and evaluate clients needs when long term care is being provided.