By: SOPHIA F. DZIEGIELEWSKI
In documenting the mental health disorder, the reason for the visit, generally referred to as the principal diagnosis, is listed first. Other existing mental disorders can be coded by simply listing them based on relevance to treatment. In addition, any supportive information and circumstances affecting the diagnosis can be documented. In practice, most clients usually present with a principal diagnosis, and it is often labeled the reason for visit. Regardless of whether the practitioner is working with adults or children, acceptable proficient documentation when there is more than one diagnosis requires that the principal diagnosis, which is also considered the reason for visit, should always be listed first.
When documenting the
diagnostic assessment, three situations need to be examined.
1. For each primary diagnosis
given, the practitioner should note the major psychiatric symptoms the client
is displaying that support its use. In the DSM-5, each of the 20 chapters that outline the mental disorders have
specific criteria associated with
it that need to be reviewed, applied, and assessed for symptom occurrence.
2. These presenting symptoms
should be clearly noted and documented concerning frequency, intensity, and
duration. The measurement scales described in this chapter can assist with
this.
a. When looking at issues of
frequency, it is critical to document how often the problem behaviors occur
during a specific time period. Are the behaviors
happening, for example, once a week or once a day? How does the frequency of occurrence of these
problem behaviors directly affect individual, occupational, or social
functioning? Many of the diagnostic categories say that the behaviors must
occur once or more; others say they must be frequent occurrences. To be safe,
always document the frequency of the behavior and how it is documented to have occurred and relate it directly to level of
functioning.
b. Intensity is another
critical aspect to be clearly identified in
assessing diagnostic criteria. To address intensity, the practitioner must
gather information about the magnitude of the strength, power, or force with which a problem behavior is occurring and relate
this directly to the way it affects daily functioning. Is the behavior affecting
the client’s abilities to form and
maintain relationships, or is it more severe, thereby affecting the client’s ability to perform
routine daily activities such as self-hygiene?
c. For duration, the
practitioner should document the time between the onset and stopping of the
behavior (Wright, 2011). Specifically,
addressing duration requires that the period of time that something lasts or exists
be measured. This period is very important in terms of identifying the criteria
for a disorder because often specific time
frames must be met (e.g., for schizophrenia, the symptoms must last
approximately 6 months; if less than 6 months, the diagnosis of schizophreniform is utilized). Suggested measures and standardized
tools can assist with this. One particularly helpful tool outlined in the DSM is the Clinician-Rated Dimensions of Psychosis Symptom Severity scale discussed earlier. Such measures
can help the practitioner measure incidence and problem behaviors (in terms of
frequency, intensity, and duration).
3. When substantiating the
categorization of diagnostic criteria supportive of the mental health
diagnosis, environmental, cultural, and social factors must always be assessed,
it can be difficult to separate behaviors
that are culturally based from those that are not. In the diagnostic
assessment, the expectation is not to diagnose disorder(s) when an individual’s behaviors are related to
a cultural situation or syndrome. In the diagnostic assessment process, if the
practitioner believes the behavior is culture related, no clinical syndrome or
formal diagnosis constituting a mental disorder based on those symptoms alone
is given. Use of the CFI is highly recommended, and based on the results,
caution should be used in terms of diagnosing someone with a mental disorder,
even if the symptoms displayed seem to suggest it. (See Quick Reference 3.13.)
QUICK
REFERENCE 3.13
|
Questions to Guide the Process
■ What are the major psychiatric symptoms a client is displaying? ■ What are the frequency, intensity, and duration of the symptoms or problem behavior? ■ Do the symptoms identified fit the dimensional criteria outlined for the disorder in the DSM-5? ■ Has a complete diagnostic assessment been conducted that utilizes assessment measures such as Cross-Cutting of Symptoms, the WHODAS, and the Symptom Severity Scale? ■ Has supportive information been evaluated such as environmental factors, cultural and social factors, and have these aspects been considered as a possible explanation? |
For all clients,
misdiagnosis or absence of the proper diagnosis can have devastating effects. When a client is extremely agitated and uncooperative, the practitioner should
assess to see if this type of behavior is characteristic of any other time in the client’s life. If it is not, the behaviors could be related to an unknown trauma such as a closed head injury.
Non-recognition of the
medical aspects of a mental disorder could also result in severe legal,
ethical, and malpractice considerations. It is essential for non-medically
trained mental health practitioners to have some background in medical
conditions, particularly the influence
these conditions have on mental health symptoms.
To guide the diagnostic
assessment and screening inquiries that help to identify the relationship
between medical factors and mental health–related behaviors,
Pollak et al. (1999) suggested three guidelines that remain relevant.
1. The practitioner should
look for risk factors and whether the client falls into a high-risk group as
identified earlier.
2. The practitioner should
consider whether the presentation is suspicious or inconsistent and therefore
suggestive of a neurodevelopmental or medical condition.
3. After gathering initial
screening information, the practitioner should decide whether further testing
is warranted to address the physical or medical basis of the
symptoms a client is experiencing. In this case, a physical exam should always be
considered.
Once the practitioner makes
a referral, the client will need to sign a release for the physician to share this information with the mental health practitioner. The practitioner
is also advised to use client information from previous history and physical
exams, medical history summaries, radiological reports, and lab findings. The most valuable
advice for the practitioner is to first establish
when the client last had a physical exam. When this information cannot be verified and the practitioner is
not sure whether the condition is medically based, referral for a physical exam
should be made.
Although the mental health
practitioner can assist in identifying and documenting medical conditions,
remember that the original diagnosis of any such medical condition always rests
with the physician or the medical provider (see Quick Reference 3.14).
QUICK
REFERENCE 3.14
|
Helpful Hints: Clinical Presentations Suggestive of a Mental
Disorder
■ Previous psychosocial difficulties not related to a medical or other type of developmental disorder. ■ Chronic unrelated complaints that cannot be linked to a satisfactory medical explanation. ■ A history of object relations problems, such as help-rejecting behavior, codependency, and other interrelationship problems that significantly impair social functioning. ■ A puzzling lack of concern on the part of the client as to the behaviors he or she is engaging in with the tendency to minimize or deny the circumstances. ■ Evidence of secondary gain where the client is reinforced by such behaviors by significant others, family, or members of the support system. ■ A history of substance abuse problems (legal or illegal substances such as alcohol or prescription medication abuse). ■ A family history of similar symptoms and/or another mental disorder. ■ Cognitive or physical complaints that are more severe than what would be expected for someone in a similar situation. |
'Also, please keep in mind
that DSM-5 no longer gives the “ICD-9 Codes for the Selected
Medical Conditions and Medication-Induced Disorders” that were in Appendix G of
the DSM-IV-TR. Therefore, where using
the ICD-10 medical condition codes is
essential for diagnostic and billing purposes, obtaining the codes from ICD would be expected.
Pollak et al. (1999)
suggested several factors to help a practitioner separate mental health
clinical presentations that may have a medical contribution. Eight points
should always be considered in completing the diagnostic assessment:
1. Give special attention to
clients who present with the first
episode of a major disorder. In these clients, particularly when symptoms are
severe (e.g., psychotic, catatonic, and nonresponsive), close monitoring of the
original presentation, when compared with previous behavior, is essential. Note if the client’s symptoms are acute (just started or relative to a certain
situation) or abrupt with rapid changes in mood or behavior. Examples of
symptoms that fall in this area include both cognitive and behavioral symptoms,
such as marked apathy, decreased drive and initiative, paranoia, labile mood or
mood swings, and poorly controlled impulses.
2. Pay particular attention
when the initial onset of a disorder or serious symptoms occurs after the age
of 40. Although this is not an ironclad rule, most mental disorders become
evident before the age of 40; thus a later onset of symptoms should be
carefully examined to rule out social or situational stressors, cultural implications,
organic concerns, or other environmental or medical causes.
3. Note symptoms of a mental
disorder that occur immediately before, during, or after the onset of a major
medical illness. The symptoms may be related to the progression of the medical
condition. It is also possible that symptoms could be medication- or substance-related (Dziegielewski, 2010). Polypharmacy can be a problem for individuals who are
unaware of the dangers of mixing medications and substances that they do not
consider medications (e.g., herbal preparations) (Dziegielewski, 2010).
4. In gathering information
for the diagnostic assessment, note whether there is an immediate psychosocial
stressor or life circumstance that may contribute to the symptoms the client is
experiencing. This is especially relevant when the stressors present are so
minimal that a clear
connection between the stressor and the reaction cannot be made. One very good general rule is to remember that anytime a client presents with extreme symptomology of any kind, with no previous history of such behaviors, assessment and possible attention and monitoring for medical causes is essential.
connection between the stressor and the reaction cannot be made. One very good general rule is to remember that anytime a client presents with extreme symptomology of any kind, with no previous history of such behaviors, assessment and possible attention and monitoring for medical causes is essential.
5. Pay particular attention in
the screening process when a client suffers from different types of
hallucinations. Basically, a hallucination is the misperception of a stimulus.
In psychotic conditions, auditory hallucinations are most common. When a client
presents with multiple types of hallucinations —such as
visual (seeing things that are not there), tactile (referring to the sense of
touch, e.g., bugs crawling on them), gustatory (pertaining to the sense of
taste), or olfactory (relative to the sense of smell)—this is generally too
extreme to be purely a mental health condition. It could be substance related
or medically based; therefore, a referral of collaborative teamwork with a
medically trained professional is expected. Be sure a medically
trained practitioner is aware of these symptoms and how they can relate to the mental health diagnosis.
trained practitioner is aware of these symptoms and how they can relate to the mental health diagnosis.
6. Note any simple repetitive and purposeless movements of speech (e.g., stuttering or indistinct or unintelligible speech), the face (e.g., motor tightness or tremors), and hands and extremities (e.g., tremor, shaking, unsteady gait). Also note any experiential phenomena such as derealization, depersonalization, or unexplained gastric or medical complaints and symptoms, such as new onset of headache accompanied by nausea and vomiting.
7. Note signs of cortical
brain dysfunction, such as aphasia (language disturbance), apraxia (movement
disturbance), agnosia (failure to recognize familiar objects despite intact
sensory functioning), and visuo-constructional deficits (problems drawing or reproducing objects and patterns).
8. Note any signs associated
with organ failure, such as jaundice related to hepatic disease or dyspnea (difficulty breathing) associated
with cardiac or pulmonary disease. For example, a client who is not getting
proper oxygen may present as very confused and disoriented; when oxygen is
regulated, the signs and symptoms begin to decrease and quickly subside. Although
mental health practitioners are not expected to be experts in diagnosing
medical disorders, being aware of the medical complications that influence mental health
presentations is necessary to facilitate the most accurate and complete
diagnostic assessment possible.
References
SOPHIA F.
DZIEGIELEWSK, 2015, DSM-5TM
in Action, by John Wiley & Sons, Inc.
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