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Diagnostic Assessment (DA) Report Components

Revised: 12-19-2017

Diagnostic Assessment (DA) Report Components

Brief

Standard

Extended

Adult update: For areas marked in this section there must be a review and written update of those parts where significant new or changed information exists and document where there have been no significant changes.

Client's current life situation

Age

x

x

x

x

Current living situation, including household membership and housing status

x

x

x

Basic needs status including economic status

x

x

x

Education level and employment status

x

x

x

Significant personal relationships, including the client's evaluation of relationship quality

x

x

x

Strengths and resources including the extent and qualify of social networks

x

x

x

Belief systems

x

x

x

Contextual non personal factors contributing to the clients presenting concerns

x

x

x

General physical health and relationship to client's culture

x

x

x

Current medications

x

x

x

Reason for the assessment

Description of symptoms including reason for referral

x

x

x

x

Perception of his or her condition

 

x

x

x

History of mental health treatment including review of records

 X

x

x

x

Developmental incidents

 

x

x

x

Maltreatment or abuse

 

x

x

x

History of alcohol and drug abuse

 

x

x

x

Health history and family health history

 

x

x

x

Cultural influences and impact

 X

x

x

X

Mental status exam

x

x

x

x

Assessment of client needs based on baseline measurements, symptoms, behaviors, skills, abilities, resources, vulnerabilities, safety needs

x

x

x

Screenings used to determine substance abuse and other standardized screening instruments

 

 

 

 

CAGE-AID, GAIN-SS

x

x

x

x

Assessment methods

 

 

 

 

CASII (age 6-17), ECSII (age 0-5), SDQ (children's assessments)

 

x

x

 

LOCUS (not required at this time)

 

 

 

 

Clinical summary

 

 

 

 

Recommendations

x

x

x

x

Prioritization of needed mental health, ancillary or other services

x

x

x

x

Client and family participation in assessment

 

x

x

x

Referrals to services required by statute or rule

 

x

x

x

Service preferences

 

x

x

x

Cause, prognosis, likely consequences of symptoms

x

x

x

x

How Dx criteria is met: Symptoms, frequency and duration, functional impairment

x

x

x

x

Strengths, cultural influences, life situations, relationships, health concerns and how Dx interacts or impacts with client's life

x

x

x

x

Explain R/O, other provisional Dx, and why alternative Dx that were considered were ruled out

x

x

x

x

Diagnosis

 

 

 

 

Complete Dx using non-axial system as defined in DSM-5

x

x

x

x

For children under the age of five, use the five axial system defined in the DC:0-3R

x

x

Provisional diagnostic hypothesis plus 12 or 36 item WHODAS (adult DAs)

x

 x

 x

 x

WHODAS Information

DAs for adult recipients billed to MHCP fee-for-service must include either the 12 item or 36 item WHODAS. Refer to the following resources for the assessments, copyright information, user agreement, language translations and any other WHODAS questions:

  • • Assessments:
  • WHO Disability Assessment Schedule 2.0 12-item
  • WHO Disability Assessment Schedule 2.0 36-item
  • WHODAS 2.0, proxy administered (including copyright information and rights to reproduce)
  • • Guidance:
  • User support and translation details
  • User agreement for electronic usage of WHODAS assessment
  • Simple scoring method
  • WHO Frequently Asked Questions (FAQ)
  • Legal References

    MN Rules 9505.0372, subpart 1, items A-E

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