1) Diagnosis Form  |
This form allows you to
document (and print, if desired) the diagnosis for this client. Whatever
you put as the first diagnosis in the Axis I field will be the diagnosis
automatically inserted in the session note screen when you tab into
the Dx field. If there is none, then you will have to manually put the
Axis II diagnosis in that field. |
| 2) Prior
|
The assumption is that you will not
need to refer back to this form very often as you continue in your
work with the client, so when you come into this form, you are presented
with a blank form for new input. If you do want to see the client's
last diagnosis document, click this button.
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| 3)
Print |
This button allows you to view a printable
copy of your diagnosis.
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| 4)
Therapist |
This is the therapist who conducted
the interview. This is a left-over field from when this system was used
for a multi-therapist clinic.
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| 5)
Date of Diagnosis |
This is the date of the session in which
the diagnosis was determined. The first diagnosis will be derived in
the first session, so the date of diagnosis will be the date of the
intake (admission). After that, you can put any date in this field that
you want. Generally, it should coincide with a session that were you
document the new symptoms that justified the new diagnosis, so the justification
field should match the session note of the same date.
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| 6)
Source Session |
Indicate whether this diagnosis was
determined during the first session (the intake session), or some subsequent
session. Select it from the drop-down box.
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| 7)
Diagnosis Type |
Indicate if this is a formal diagnosis
in which you have complete confidence, or if this is just a preliminary
diagnosis until other sessions will confirm. Since you are required
to have a diagnosis to submit claims, you do not have the option of
waiting. Use this field or the "R/O (rule-out)" field to indicate
your level of confidence in your diagnosis. |
| 7)
Justification |
Indicate the symptoms you observed or
were reported to you that justify your diagnosis. In general, I will
use the "Problem" paragraph in the Intake document, so if
you have come to this diagnosis screen from the Intake form, the "Problem"
field will be automatically populated into the justifcation field. You
can change it if you would like. |
| 7)
Axis I Diagnosis |
This is the standard Axis I diagnosis.
The first screen print above shows what happens when you start typing
the diagnosis. In the example, I have typed the word "post"
and "Posttraumatic Stress Disorder" is automatically populated
into the field. It chose that diagnosis because that is the only diagnosis
in the system that starts with those four letters. As you start typing,
you will see diagnoses appear. Keep typing until the one you want comes
up. If it is too long, such as with Major Depressive Disorder, then
just start typing the first few letters, then click the arrow to the
right (see the big red arrow pointing to the right of the drop-down
list on the second screen above). The drop-down listing will open up
with the first diagnosis that matches what you have typed so far. Then
you can select the correct diagnosis off of the drop-down list. |
| 7)
Axis II Diagnosis |
This is the same as the Axis I Diagnosis
drop-down box. |
| 7)
Axis III and IV |
This is just free-form text input for
these two Axes. |
| 7)
Axis V |
This is free-form text input for the
GAF. |
| 7)
Additional Information |
This is free-form text input. I added
this box to the diagnostic screen because there are occasions where
you want to document additional information supporting or explaining
the diagnosis. For instance, for Adjustment Disorder, you may want to
document what they are adjusting to separately from the full justification.
Nothing is required here. |
