Puling It All Together in Completing the Diagnostic Assessment

By: SOPHIA F. DZIEGIELEWSKI

For a comprehensive diagnostic assessment, it is assumed that the screening begins with the first client–mental health practitioner interaction.

The information the mental health practitioner gathers is assembled into a database that facilitates the diagnostic assessment and determines the requirements and direction of future treatment planning and intervention efforts. The diagnostic assessment assists in ordering information on the client’s present situation and history in regard to how past behaviors can relate to present concerns. This comprehensive assessment is inclusive, supporting both clinically based judgments and interpretation of perspectives and alternatives for service delivery.

To start this process, the problem must be recognized as interfering with daily functioning. Here the practitioner must be active in uncovering problems affecting daily living and engaging the client in self-help or skill building, changing behaviors, or both. The client has to acknowledge that the problem exists. Once this is done, the definition of the problem becomes clear, allowing for exploration (Hepworth, Rooney, Rooney, Gottfried, & Larsen, 2010).

In addition, the problem must be clearly identified. The problem of concern is what the client sees as important; he or she is the one who is expected to create the behavior change. It is common to receive referrals from other health care professionals, and special attention should always be paid to referrals that clearly recommend a course of treatment or intervention. This type of focused referral may limit the scope and intervention possibilities available.

Often such focused referrals that limit intervention scope can provide the basis for reimbursement as well. Although referral information and suggestions should always be considered in your discussion with the client in identifying the problem, in terms of assessment and the resulting plan, the client’s best interest is paramount, and he or she should participate to identify the end result.

Generally, the client is the primary source of data. This information can be supplemented through direct observation of verbal and physical behaviors and through interaction patterns with other interdisciplinary team members, family, significant others, or friends. Viewing and recording these patterns of communication can be extremely helpful in later establishing and developing strengths and resource considerations.

In addition to verbal reports, written reports such as background sheets, psychological tests, and tests of health status or level of daily functioning can be used. Although the client is perceived as the first and primary source of data, the need for information from others cannot be underestimated. This means talking with the family and significant others to estimate planning support and assistance. Gathering information from other secondary sources, such as the client’s medical record, is also important.

To facilitate the diagnostic assessment, the practitioner must be able to understand the client’s medical situation and the relationship that medical symptoms can have with mental health symptoms. Knowledge of certain medical conditions and when to refer to other health professionals for continued care is an essential part of the diagnostic assessment process.

Completing a comprehensive assessment has three primary steps:

1. Problem or behavior recognition. Here the practitioner must explore and be active in uncovering problems that affect daily living and will later be targeted in engaging the client in self-help or skill changing behaviors. The client has to acknowledge that the problem exists. Once the problem is acknowledged, the boundaries related to the problem become clear (Hepworth et al., 2010).

2. Problem or behavior identification. In the diagnostic assessment, problems that affect daily functioning are identified. What the client sees as the problem of concern is important for helping the client to develop change behavior. In the mental health field, referrals that often provide the basis for reimbursement are common, and sometimes the referral source establishes how the problem is viewed and what should be the basis of intervention. Sound, efficient, cost-effective clinical practice takes referral information into account because it can lead to better problem identification.

3. Treatment plan. Once the diagnostic assessment is complete, how will the information be related to the intervention plan and strategy to follow? According to Sheafor and Horejsi (2012), the plan of action is central to bridging the diagnostic assessment with the resultant practice strategy. Here the practitioner focuses on the goals and objectives to be attained in the intervention process. In the initial planning stage, emphasis on the outcome is essential The outcome of the diagnostic assessment process is a plan to guide, enhance, and in many cases determine the course of intervention to be implemented.

Given the complexity of human beings and the problems they encounter, a properly prepared multidimensional assessment is the essential first step to high-quality service delivery. The diagnostic assessment should never be considered a static entity, or else it may become too narrow in focus, thereby decreasing its utility, relevance, and salience. The process of diagnostic assessment must continually be examined and reexamined to ensure its quality. This process should not be rushed because when it is, superficial factors may be highlighted and significant ones de-emphasized or overlooked.

Mental health practitioners owe it to their clients that diagnostic efforts and the helping strategy that develops are quality driven, no matter what the administrative and economic pressures may be. This support is just one of the ways practitioners are working not only to assist in developing a comprehensive strategy to help clients but also to ensure that high-quality service is available and obtained.

References

SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons, Inc.

Read Also

Completing the Diagnostic Assessment

The Psychiatric Evaluation

The Clinical Interview

Diagnostic Principles

PRINCIPAL AND PROVISIONAL DIAGNOSIS

DIAGNOSTIC AND TREATMENT APPLICATIONS

Documentation of diagnostic assessment of the mental health disorder
The Comprehensive Diagnostic Assessment and Evaluation
WHODAS: Assessing Disability
Coding Medical Conditions
Brief History of the DSM
The Person-in-Environment Classification System (PIE)
The official nomenclature used in mental health and other health-related facilities
The International Classification of Diseases (ICD)