A successful diagnostic process adequately notes the full extent of a client’s problems – in areas related to health, mental health and the complex relationship between the two. In such instances, do not record a diagnosis as if certainty had been reached. Since the introduction of the DSM-II in 1968, the purpose behind refinements to the diagnostic process is to create increased clarity about the full nature and extent of a client’s condition. If this is not possible then the practitioner needs to discuss referral options with the individual. For example, Persistent Depressive Disorder requires that symptoms be present for a period of two years prior to a diagnosis being made. Some of these choices are noted and formally endorsed within the DSM-5. In such instances - where there are transient symptoms that look like a mental health problem - a mental health diagnosis would not be appropriate to note on a patients record. It is important for clinicians to have a thorough understanding of how to use these specifiers. Additionally, the use of specifiers provides the opportunity to show specific, measurable changes in client progress from one session to the next. DISCUSSION: This case study describes how physical therapists’ ability to use clinical decision making when considering alternative physical therapy clinical impressions can lead to a better outcome for patients who make therapeutic improvements but continue to experience pain. Significant psychosocial and contextual features: Financial instability and housing insecurity affect the ability of the client to access treatment on a regular basis.
The clinical impression can assist the practitioner in deciding how to focus the psychosocial assessment process. https://sophia.stkate.edu/dpt_papers/16, Home | Common Medical Diagnoses Likely to Be Encountered. These practice centers can be either private or public settings and provide services that range from psychiatric to medical/ surgical interventions, or skilled medical such as home health. An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process.
In addition to the “rule out” specifier that is commonly used within diagnostic summaries to provide greater clarity about a client, Heimsch & Polychronopoulos (2009) point out a few other informal diagnostic labels not listed in the DSM-5 that can be helpful in communicating additional information. In such instances, there are two possible choices. A physical therapy evaluation is the synthesis of all the information you gather during a physical therapy examination. Part of your clinical impression needs to account for your ability to comfortably accommodate the individual’s preferences and establish and maintain a strong therapeutic relationship. This approach can include the addition of some clarifying text with the diagnosis: “Client’s symptoms have not been present for sufficient time to meet criteria.” This will alert other clinicians as to the circumstances being addressed. This process is made considerably more challenging in a patient with a complicated surgical history. (2012). When all information points to arriving at that diagnosis, but the specified period of time has not yet elapsed, e.g., less than two years, the diagnosis may be noted as provisional until the time criteria have been met. It is a combination of the evaluation of the presenting problem and any other issues that the practitioner discovers during the assessment process. For this reason, the clinical impression can explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows. There are diagnoses where the criteria include a requirement for the symptoms to be present for a specified period of time. Soap … When enough information has been gathered from the assessment to arrive at a diagnosis, you refer to the DSM to get the numeric code and list it in the client’s record. repository website:
Clinical Impression Example. [Harel TZ, Smith DW & Rowles JM (2002) A comparison of psychiatrists’ clinical impression based and social workers computer generated GAF scores. For every diagnosis you include, write out the diagnosis beside the numeric code. Other and Specialized Courses and Products. Clinical Impression Example Mental Health.
There are a number of choices of how to record the client’s problems in ways that clarify this state of uncertainty about the diagnosis.
OUTCOMES: Over the course of eleven treatment sessions the patient made gains in lower extremity strength and soft tissue mobility in the affected leg and met his functional goals. the etiological medical condition be listed first. DISCUSSION: This case study describes how physical therapists’ ability to use clinical decision making when considering alternative physical therapy clinical impressions can lead to a better outcome for patients who make therapeutic improvements but continue to experience pain. Moreover, there is information present in the history that may point in a different direction. Obviously, the diagnosis for any primary medical condition would be determined not by the mental health clinician, but by the physician assessing and treating the medical condition. It is the practitioner’s responsibility to communicate to the individual that the relevance and effectiveness of the assessment and resulting intervention is directly related to the accuracy and completeness of the information provided.
The new codes, with up to seven digits, will allow for the recording of additional specifiers within the code numbers. It is more appropriate to use “provisional” when symptoms suggest that a diagnosis is likely, but more information is needed to reach a point of clear confirmation. In addition to the options noted above, there are circumstances in which the client’s presentation does not suggest the presence of any diagnosable mental health condition. Omitting this information can create difficulties if other medical personnel – who are not mental health specialists - are involved in the treatment of the patient.
The individual or family being assessed must be empowered to participate, to identify priorities, to develop intervention activities that are relevant and appropriate to a positive outcome. For instance, clients may present with a disorder that can occur with different manifestations, as in the case of Bipolar Disorder, which can appear with a primarily manic phase or a primarily depressed phase. [ Kennedy, JA (2003) Kennedy Axis V (K Axis) from www.kenedymd.com] This will include physical appearance, mood and affect, communication strengths, deficits and style, the level of cooperation and functional ability, any legal or financial issues as well as the consistency of the information being provided. Problem focused assessments are helpful for individuals who need “fixes” like linkage to specific services, medical interventions or pharmacological management. The mental health clinician would only have that information because it would be forwarded to her/him through case coordination. Because the clinical impression is subject to the practitioner’s personal biases and opinions, it is important to minimize these risks. Gait training therapy (97116) Therapeutic activities (97530) Electric stim other than wound (G0283) Diathermy treatment and/or microwave therapy (97024) Frequency: 5 time(s)/week Duration: 8 week(s) Intensity: Daily Cert. There is no substitute for time, study and repetition. We’re quoting this one from the book “Functional Outcomes – Documentation for rehabilitation” found on page 125. Clinical Decision Making and Physical Therapy Management of Knee Pain Following Total Hip Arthoplasty: A Case Report. The creation of new forms must create the necessary room to include the more expanded diagnoses with numerous specifiers. In addition, the practitioner needs to be aware of the individual’s preferences for style of assessment, gender of the practitioner, and availability for completing the assessment process.