Some of these are not noted formally in the DSM-5, but are widely used and understood by clinicians as methods to record the diagnostic uncertainty that is present. (2012). Let’s take a look at a detailed physical therapy SOAP note example. Problem focused assessments are helpful for individuals who need “fixes” like linkage to specific services, medical interventions or pharmacological management.

An example of this is shown below: Diagnosis:  Alcohol Use Disorder, Moderate                                                 _   Code: F10.20, Diagnosis:  Attention Deficit Hyperactivity Disorder, Combined Presentation  Code: F90.2. Let us take for an example a client who presents for treatment with some of the signs and symptoms of serious depression, with the data from the gathered history suggesting a possible diagnosis of Major Depressive Disorder, Recurrent, Moderate (296.32). Additionally, the order and manner in which information is presented will list the most important information first - and with maximum clarity – in order to inform best treatment choices.

It should also identify the antecedent factors and environmental influences that affect the person’s situation as well as the individual’s positive strengths, attributes and competencies. Below is an example of how psychosocial and environmental factors would be recorded under the old and new systems: Axis IV: Housing uncertainty, financial stresses, social isolation. Once the necessary period of time has been reached, the diagnosis can be changed to remove the provisional specifier. It is preferable to use an “unspecified” diagnosis rather than a deferred diagnosis, if clinically indicated. The approach is an evolving system, constantly seeking to find the best balance between comprehensiveness and concision. There will instead be an expansive and comprehensive set of codes that will cover all conditions previously denoted on the Axis I-IV, and each will be recorded without reference to an axis.

There are several important considerations to address concerning the many aspects of this process of recording diagnoses. A concise and thorough assessment allows for more efficient and rapid sharing of that information among all treatment providers. evaluating the information using several theoretical models, being aware of and controlling your own cultural biases, eeking alternative explanations of the data, the individual’s goals for the assessment and the resulting intervention, “The individual appears to be a reliable informant with sincere commitment to achieving goals by adherence to the developed treatment plan.”, “The individual exhibits moderate difficulty in social and occupational functioning that is compounded by significant medical, financial and legal problems.”, “Some mild psychological problems are evident, but the individual has a strong social support network and financial resources.”, "The individual is an unreliable informant related to substance abuse, severe psychological symptoms, unstable life situation and impaired social skills.”, elected to abandon the use of the multi-axial system, write out the diagnosis beside the numeric code.

Clinical Decision Making and Physical Therapy Management of Knee Pain Following Total Hip Arthoplasty: A Case Report. > Marais, Lisa. Even if the client does not present with complicated conditions with several specifiers, it is important to write out the diagnosis in full in addition to the correct diagnostic code. With the implementation of ICD-10-CM, the code will move from a format that allows up to five digits (e.g., 296.32, Major Depressive Disorder, Recurrent Episode, Moderate) to a format that allows for up to seven digits (e.g., F40.232, Specific Phobia, Fear of Medical Care).

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