Diagnostic/ Assessment (MH/DD/SA)
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What is a diagnostic assessment?
A Diagnostic Assessment is an intensive clinical and functional face to face evaluation of an individual's mental health, developmental disability, or substance abuse condition that results in the issuance of a Diagnostic Assessment report with recommendations regarding whether the recipient meets target population criteria, and includes an order for enhanced benefit services that provides the basis for the development of an initial Person Centered Plan.
For substance abuse-focused Diagnostic/ Assessment, a designated Diagnostic Tool for specific substance abuse target populations (i.e., Work First, DWI, etc.) will be used. In addition, any elements included in this service definition must include the following elements:
- a chronological general health and behavioral health history( includes both mental health and substance abuse) of the recipient’s symptoms, treatment, treatment response, and attitudes about treatment over time, emphasizing factors that have contributed to or in habited previous recovery efforts;
- biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weakness in each area;
- a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions; and current medications
- A strengths/problem summary which addresses risk of harm, functional status co-morbidity, recovery environment, and treatment and recovery history;
- Diagnoses on all five axes of DSM-IV;
- Evidence of an interdisciplinary team progress note that documents that team’s review and discussion of the assessment;
- A recommendation regarding target population eligibility; and
- Evidence of recipient participation including families, or when applicable, guardians or other caregivers.
The assessment will be signed and dated by the MD, DO ,PA, NP, licensed psychologist and will serve as the initial order for services included in the PCP.
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