Bethune Best ONLY #3

Diagnostic Report and Treatment Planning

(with Template to add after Case History of “Sally” in blue)

Screening Results. Add your screening information, but only on Substance Use Disorders, not on Mental Health disorders.

Assessment Results. After adding Screening Results, place other Substance Use Disorder Tests you would have given if this was your case.

Diagnostic Impressions are added next in a paragraph of cumulative analysis of all the criteria you have thus far on Sally.

Diagnosis/Diagnoses are next listed using the DSM-5 codes and descriptions. Match the SUD and/or Mental Health disorder descriptions and codes as you develop the DSM-5 list. The Doweiko text will also assist. Only diagnose what you are certain of. Evaluation is an ongoing process and need not be completed from day one.

Recommendations are needed next. Include Spirituality/Faith in those recommendations remembering to address Informed Consent as needed.

BioPsychoSocialSpiritual (BPSS) assessment is placed here and is paramount to creating a treatment plan that offers best practice services. The BPSS and BPSS Summary sample outlines are added here.

Treatment Plans follow and are then outlined utilizing Perkinson’s Goals, Objectives and Interventions.

Conclusion and a Reference list follow and are placed at the end.

*********************************Template***********************************

Case History for Treatment Plan

Report Regarding Sally Smith

Name: Sally Smith

SS#: 000-00-0000

Age: 42 years old

Date of Examination: 9/1/2016

Examiners: Fred Looney, PhD

Chief Complaint: Mental functioning

Sources of Information

Clinical Interview with Sally Smith

Medical Records

Brief Mental Status Examination

Wechsler Adult Intelligence Scale-IV (WAIS-IV)

Background Information

Ms. Smith is a 42-year-old African American female. She currently lives with her mother. She states she has one adult son from a prior marriage. Ms. Smith states she has a 2-year nursing degree and was employed as a nurse until 2015. She indicates that she does not attend church currently, but her mother attends on a weekly basis. As a child, she attended Sunday school and church periodically.

Ms. Smith states that she has been unable to work as a nurse due to medical problems. She reported that for years she had problems with high blood pressure, and, one day, she passed out and was put on a respirator. With further questioning, she reports that, on the day of this hospitalization, she drank an alcoholic beverage that reportedly was laced with “some drug.” Her medical records show a positive drug screen of benzodiazepines. The medical records state she was “brought in a comatose state” and was intubated.

The doctor’s records state that Ms. Smith had told him she had been taking OxyContin for pain and had gone to lunch with friends and had two drinks. When asked about the information in the medical records, Ms. Smith admitted to some problematic drinking during a one-year time frame. However, her reported history and the medical records do not coincide. Medical records report a diagnosis of alcohol poisoning.

Her medical history includes inflammatory bowel disease, acute gastritis, atypical chest pain, hypertension, and a history of alcohol abuse with elevated alcohol levels during admission. Ms. Smith states she has a history of depression and was admitted to a state hospital in 2016 due to suicidal ideations. She states her abusive alcoholic drinking is related to her depression. She does admit to consuming a “small” bottle of vodka on a daily basis at the height of her drinking. She denies any current alcohol use and is reportedly under the care of a doctor. She states her current diagnosis is bipolar disorder. She reports that she hears voices in her head and, at times, verbally responds to them. Ms. Smith was not able to list the medications she is currently on, nor are there any recent medical records as to her current medical conditions. Most recent record is January 2016.

Mental Status and Behavioral Observations

Attitude and Behavior: Ms. Smith was friendly and cooperative throughout the interview. She appeared to respond in a genuine manner when asked questions. At times, however, she appeared to be confused with the information requested of her. Her speech was slurred at times, and she had a glazed look about her.

Appearance: Ms. Smith appeared neat but casually dressed. She seemed to show adequate attention to her grooming needs. Ms. Smith did appear to have a slight odor, seemingly of alcohol.

Quality of Thinking: Ms. Smith’s thinking appears pressured and unorganized. Her reported history does not follow written reports; however, she does not appear to understand the inconsistencies. Her self-report appears to be what she believes to be her honest answer.

Abstraction Skills: Ms. Smith’s abstract thinking appears very limited; she was unable to explain how work and play are similar or why people are put on parole.

Affect and Mood: Ms. Smith appeared docile and cooperative throughout interview. However, the examiner continually needed to redirect her and help keep her focused.

Orientation: Ms. Smith was oriented x’s 3.

Memory: Ms. Smith’s memory appears limited as evident in her ability to only repeat 4 numbers forward and 3 backwards.

Attention and Concentration: Ms. Smith appeared to attend to all tasks at hand.

Judgment and Insight: Ms. Smith’s judgment and insight appear limited in her inability to follow logical order and recognize inconsistencies.

Intellectual Functioning Testing Results and Interpretations

Wechsler Adult Intelligence Scale-IV (WAIS-IV)

WAIS–IV Scale Score

Verbal Comprehension 67 (Extremely Low)

Perceptual Reasoning 73 (Borderline)

Working Memory 73 (Borderline)

Processing Speed 100 (Average)

Full Scale 67 (Extremely Low)

General Ability 99 (Average)

Ms. Smith is functioning in the Extremely Low range of intellect, with her Verbal Comprehension Index score significantly, but not rarely, lower than her Working Memory and Processing Speed. In addition, her current functioning is inconsistent with reported prior achievement and functioning.

Diagnostic Report and Treatment Planning

SUD Screening Results

SUD Assessment Results

Diagnostic Impressions

Diagnosis

Recommendations

BPSS Assessment for “Sally” (Sample of this portion)

Bio-Psycho-Social-Spiritual Assessment

Family History – Current Family:

Family History – Family of Origin:

Vocational/Educational/Financial History:

Military History:

Legal Assessment:

Social/Leisure Assessment:

Spiritual/Cultural History:

Psychological Assessment:

Sexual History and Orientation:

Problem Areas:

Problem #1:

Problem #2:

Problem #3:

Problem #4:

Problem #5:

BPSS Summary

Identifying Information, Name, Marital Status, Residence, Employment, Referral, Family Situation, Reason for entering treatment, Alcohol/Drug History, Medical Assessment, Mental Status, Psychological Summary, Relapse Issues, Problem Areas: (additional?)

Treatment Plan (Problems 1-5) (Sample this portion)

PROBLEM #1:

GOAL:

Intervention:

1A.

1B.

1C.

PROBLEM #2:

GOAL:

Intervention:

2A.

2B.

2C.

PROBLEM #3:

GOAL:

Intervention:

3A

3B.

3C.

PROBLEM #4:

GOAL:

Intervention:

4A

4B.

4C.

PROBLEM #5:

GOAL:

Intervention:

5A

5B.

5C.

Conclusion

References