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Argosy University

Documentation for Grand Rounds Paper:


C7458 DIAGNOSIS & TREATMENT PLANNING

Faculty Information
Faculty Name: David Moore, Ph.D. CDP
Contact Information: ddmoore@argosy.edu; 206.393.3548

Short Faculty Bio: Dr. Moore is an Associate Professor of the Counseling Psychology Department at Argosy
University/Seattle. He was awarded both his M.Ed and Ph.D. in Counseling Psychology from the University of
Washington/Seattle. After initiating along with teaching graduate-level behavioral science courses in the
College of Education at the Universities of Washington and Puget Sound, he served as a research faculty
member at Johns Hopkins School of Public Health’s Department of Mental Health.

Patient handouts from


The Paper Office.
Copyright 2003 by
Edward L. Zuckerman.
Permission to photocopy
this form is granted to
purchasers of this book
for personal use. The
original set of handouts is
located in the Argosy-
Seattle Library. There are a
total of approximately 80
PDF and RTF forms
available for student study.
The selected forms in this
binder is to complete the
final assignment of Grand
Rounds for Course C7458.

All forms are to be


completed based on the
“patient” you select.

Your classmates will receive all the documents on the right hand side of the graphic. The Progress Notes
should be a summary of three hypothetical sessions you have with the client. That is attached to the
Individualized Treatment Plan [called the “Case Formulation”]. In addition it is expected that you will
provide a two page paper describing the unique issue in the case; along with 1-2 journal articles that
amplify on your discussion.

Dr. Moore will also receive your two Information Forms and a Client Termination Form that describes
the ending and referrals for the client.

The goal of this comprehensive approach is to have each student complete an in-depth evaluation that
would have enough information that it could be used as a teaching case.
Page 1
Client Information Form 1
Today’s date:

Note: If you have been a patient here before, please fill in only the information that has changed.

A. Identification
Your name: Date of birth: Age:
Nicknames or aliases: Social Security #:
Home street address: Apt.:
City: State: Zip:
Home/evening phone: e-mail:
Calls or e-mail will be discreet, but please indicate any restrictions:

B. Referral: Who gave you my name to call?


Name: Phone:
Address:

May I have your permission to thank this person for the referral? ❑ Yes ❑ No
How did this person explain how I might be of help to you?

C. Your medical care: From whom or where do you get your medical care?
Clinic/doctor’s name: Phone:
Address:
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can
be fully informed and we can coordinate your treatment? ❑ Yes ❑ No

D. Your current employer


Employer: Address:

Work phone: Calls will be discreet, but please indicate any restrictions:

(cont.)
FORM 23. Client demographic information form (p. 1 of 3). From The Paper Office. Copyright 2003 by Edward L.
Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Client Information Form 1 (p. 2 of 3)

E. Your education and training


Dates
Adjustment Did you
From To Schools Special classes? to school graduate?

F. Employment and military experiences


Dates
From To Name of military or employers Job title or duties Reason for leaving

G. Family-of-origin history
Current age (or Illnesses (or cause of
Relative Name age at death) death, if deceased) Education Occupation
Father

Mother

Stepparents

Grandparents

Uncles/aunts

Brothers

Sisters

(cont.)
Client Information Form 1 (p. 3 of 3)

H. Significant nonmarital relationships

Person’s age Your age Your age


Name of other person when started when started when ended Reasons for ending
First

Second

Third

Current

I. Marital/relationship history

Spouse’s age at Your age at Your age when Is spouse


Spouse’s name marriage marriage divorced/widowed remarried?
First

Second

Third

J. Children (Indicate which are from a previous marriage or relationship with the letter P in the last column)

Current
Name age Sex School Grade Adjustment problems? P?

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Client Information Form 2

Note: If you were a patient here before, please fill in only the information that has changed.

A. Identification
Name: Date:

B. Chief concern
Please describe the main difficulty that has brought you to see me:

C. Treatment
1. Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before?
❑ No ❑ Yes If yes, please indicate:
When? From whom? For what? With what results?

2. Have you ever taken medications for psychiatric or emotional problems? ❑ No ❑ Yes If yes,please indicate:
When? From whom? Which medications? For what? With what results?

(cont.)
FORM 24. Client clinical information form (p. 1 of 4). From The Paper Office. Copyright 2003 by Edward L. Zuckerman.
Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Client Information Form 2 (p. 2 of 4)

D. Relationships in your family of origin. Please describe the following:


1. Your parents’ relationship with each other:

2. Your relationship with each parent and with other adults present:

3. Your parents’ physical health problems,drug or alocohol use,and mental or emotional difficulties:

4. Your relationship with your brothers and sisters,in the past and present:

E. Abuse history: ❑ I was not abused in any way. ❑ I was abused. If you were abused, please indicate the fol-
lowing. For kind of abuse, use these letters: P = Physical, such as beatings. S = Sexual, such as touching/molesting, fon-
dling, or intercourse. N = Neglect, such as failure to feed, shelter, or protect. E = Emotional, such as humiliation, etc.
Your Kind of Consequences
age abuse By whom? Effects on you? Whom did you tell? of telling?

F. Present relationships
1. How do you get along with your present spouse or partner?

2. How do you get along with your children?

(cont.)
Client Information Form 2 (p. 3 of 4)

3. Your important friends, past and present:


Names Good parts of relationship Bad parts of relationship

G. Chemical use
1. Have you ever felt the need to cut down on your drinking? ❑ No ❑ Yes
2. Have you ever felt annoyed by criticism of your drinking? ❑ No ❑ Yes
3. Have you ever felt guilty about your drinking? ❑ No ❑ Yes
4. Have you ever taken a morning “eye-opener”? ❑ No ❑ Yes
5. How much beer,wine,or hard liquor do you consume each week,on the average?
6. Are there times when you drink to unconsciousness,or run out of money as a result of drinking?
7. How much tobacco do you smoke or chew each week?
8. Have you ever used inhalants (“huffing”),such as glue,gasoline,or paint thinner? ❑ No ❑ Yes If yes,which and
when?
9. Which drugs (not medications prescribed for you) have you used in the last 10 years?

Please provide details about your use of these drugs or other chemicals,such as amounts,how often you used them,
their effects,and so forth:

H. Legal history
1. Are you presently suing anyone or thinking of suing anyone? ❑ No ❑ Yes If yes, please explain:

2. Is your reason for coming to see me related to an accident or injury? ❑ No ❑ Yes If yes,please explain:

3. Are you required by a court, the police, or a probation/parole officer to have this appointment? ❑ No ❑ Yes
If yes,please explain:

(cont.)
Client Information Form 2 (p. 4 of 4)

4. List all the contacts with the police,courts,and jails/prisons you have had.Include all open charges and pending ones.
Under “Jurisdiction,” write in a letter: F = federal, S = state, Co = county, Ci = city. Under “Sentence,” write in the
time and the type of sentence you served or have to serve (AR = accelerated or alternate resolution,CS = commu-
nity service, F = fine, I = incarceration, Pr = probation, Po = parole, O = other, R = restitution).

Jurisdiction Sentence Probation/parole


Date Charge (F, S, C, Ci) (AR, I, Pr, Pa) officer’s name Your attorney’s name

5. Your current attorney’s name: Phone:


6. Are there any other legal involvements I should know about?

I. Other
Is there anything else that is important for me as your therapist to know about, and that you have not written about on
any of these forms? If yes, please tell me about it here or on another sheet of paper:

Please do not write below this line.


–––––––––––––––––––––––––––––––––––––––––––––––––––––––

J. Follow-up by clinician
Based on the responses above and on ❑ interview data ❑ records I reviewed ❑ other information
I have requested the client to complete and/or I have completed the following forms:
❑ Chemical use survey
❑ Suicide risk assessment summary and recommendations
❑ Mental status evaluation report
❑ Other:

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Individualized Behavioral/Mental Health Treatment Plan
This is for ❑ Preauthorization for initial certification ❑ Concurrent review for reauthorization of care

Date current episode of treatment began: Date last plan created:

A. Identification
Client’s name: Soc.Sec.#: ID #:
Membership #: Date of birth: Sex:
Group name/#: Certificate #:
Name of subscriber/member,and address (if other than client):
Release-of-records form(s) signed: ❑ Yes ❑ Not yet

B. Case formulation/overview

1. Presenting problem(s)/reason(s) for seeking treatment:


Impair-
Problem ment* Duration
a.

b.

c.

*Code impairment as follows (per GAF Scale): 80–90 = mild, 60–70 = moderate, 40–50 = severe, 30 or less = very severe.

2. History of presenting problem(s) and current situation (precipitants,motivations,stressors,resources/coping skills,


comorbid conditions,living conditions,relevant demographics):

3. Summary of mental status evaluation results:

(cont.)
FORM 38. Individualized treatment plan for managed care organizations (p. 1 of 6). From The Paper Office.
Copyright 2003 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only
(see copyright page for details).
Individualized Behavioral/Mental Health Treatment Plan (p. 2 of 6)

C. Present level of functioning/limitations/impairment (describe specific impairments at left, and rate degree of
functional impairment at right with GAF number [100 = none, 70 = little, 30 = significant, 10 = incapacitated] or use
descriptors):
GAF
Area of functioning rating
1. School/work functioning:

2. Intimate relationship/marriage:

3. Family/children:

4. Social relationships:

5. Psychological/personal functioning:

6. Other areas:

D. Assessment conclusions
1. Assessment of currently known risk factors:
a. Suicide: ❑ Not assessed ❑ No known behaviors ❑ Ideation only ❑ Plan
❑ Intent without means ❑ Intent with means
b. Homicide: ❑ Not assessed ❑ No known behaviors ❑ Ideation only ❑ Plan
❑ Intent without means ❑ Intent with means
c. Impulse control: ❑ Not assessed ❑ Sufficient control ❑ Moderate ❑ Minimal ❑ Inconsistent
d. Compliance with treatments: ❑ Not assessed ❑ Full compliance ❑ Minimal noncompliance
❑ Moderate noncompliance ❑ Variable ❑ Little or no compliance
e. Substance abuse/dependence: ❑ Not assessed ❑ None/normal use ❑ Overuse ❑ Abuse
❑ Dependence ❑ Unstable remission of abuse
f. Current physical or sexual abuse: ❑ Not assessed ❑ No ❑ Yes Legally reportable? ❑ Yes ❑ No
g. Current child/elder neglect: ❑ Not assessed ❑ No ❑ Yes Legally reportable? ❑ Yes ❑ No
If yes, client is ❑ Victim ❑ Perpetrator ❑ Both ❑ Neither, but abuse exists in family
h. If risk exists: Client ❑ can ❑ cannot meaningfully agree to a contract not to harm ❑ self ❑ others ❑ both
I. History that may affect current level of risk or impairment of functioning:

j. Other concerns:

(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 3 of 6)

2. Urgency estimate ❑ Emergency; immediate interventions ❑ Serious disruption of functioning; act in


next 24 hours ❑ Treatment needed; act soon/routine ❑ Wait for:

3. Diagnoses—Current best formulation


Code #
Name (indicate which is primary diagnosis with “P”) ❑ DSM-IV or
❑ ICD?

Axis I

Axis II

“Rule-outs” (other possible diagnoses to be evaluated over time):

Axis III—Significant and relevant medical conditions, including allergies and drug sensitivities:
Condition Treatment/medication (regimen) Provider Status

Axis IV—Psychosocial and environmental problems in last year; overall severity rating:
❑ Problems with primary support group ❑ Problems related to the social environment
❑ Educational problems ❑ Occupational problems
❑ Housing problems ❑ Economic problems
❑ Problems with access to health care services
❑ Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems (specify):

Axis V—Global Assessment of Functioning (GAF) rating: Currently: Highest in past year:

V Codes—Other problems that may be a focus of clinical attention:

(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 4 of 6)

E. Treatment plan (if additional problems are to be addressed, use copies of this page):
Significant improvement is to be expected, with treatment as specified, for:
Problem 1:
■ Behaviors to be changed:

■ Interventions (who does what, how often, with what resources; modality, frequency, duration):

■ Observable indicators of improvement (behaviors, reports): ■ Expected number of visits to


achieve each indicator:

■ Discharge level of problem behaviors: ■ Review date:

Problem 2:
■ Behaviors to be changed:

■ Interventions (who does what, how often, with what resources; modality, frequency, duration):

■ Observable indicators of improvement (behaviors, reports): ■ Expected number of visits to


achieve each indicator:

■ Discharge level of problem behaviors: ■ Review date:

Problem 3:
■ Behaviors to be changed:

■ Interventions (who does what, how often, with what resources; modality, frequency, duration):

■ Observable indicators of improvement (behaviors, reports): ■ Expected number of visits to


achieve each indicator:

■ Discharge level of problem behaviors: ■ Review date:

(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 5 of 6)

F. Recommended program of coordinated liaisons, consultations, evaluations, and services


1. Psychotherapy: ❑ Cognitive ❑ Behavioral ❑ Family/systems ❑ Insight-oriented ❑ Play therapy
❑ Support/maintenance ❑ Environmental change ❑ Focal group ❑ Clinical hypnosis ❑ Biofeedback
❑ Other:
CPT code(s) to be used:
2. Support groups: Twelve-Step program: ❑ AA ❑ NA ❑ Overeaters ❑ Gamblers ❑ Other
❑ Other community support groups:
Psychoeducational groups: ❑ Parenting skills/child management ❑ Communication skills
❑ Stress management ❑ Assertiveness ❑ Women’s issues ❑ Other:
Ancillary services: ❑ Pain clinic ❑ Back school ❑ Physical therapy ❑ Other:
3. Legal services: ❑ Offender program ❑ Sex ❑ Substance abuse/dependence ❑ Other:
❑ Victim support ❑ Referral to emergency services/advocates:
4. Referrals for continuing services
Referred to For (kind of service) Date of referral
Psychotropic medications
Physical medical care
Psychiatric evaluation
Patient education
Nursing care
Educational/vocational services
Occupational/physical therapy
Other:

5. Further assessments, based on current clinical evaluation, are needed to answer these concerns or rule out
these possible coexisting conditions:
❑ Psychological presentation/symptoms of medical condition
Likely possible sources: ❑ Thyroid ❑ Diabetes ❑ Alcohol/drug misuse ❑ Circulatory problem
❑ Neurological problem ❑ Poor nutrition ❑ Medication interactions ❑ Toxin exposure
❑ Other:
❑ Sexual dysfunctions ❑ Factitious disorders ❑ Substance abuse/dependence
❑ Psychophysiological disorders ❑ Learning disabilities
❑ Genetic disorders/counseling ❑ Other:
6. Documents to be obtained (have requests for records completed and signed,photocopied,and placed in client’s
file so that receipt can be assured):
Type of record Source Date of first request
❑ Medical/physician/hospital

❑ School

❑ Agency

❑ Other:

7. Other needed resources and services:

(cont.)
Individualized Behavioral/Mental Health Treatment Plan (p. 6 of 6)

G. Administrative
1. Case manager’s additional suggestions for treatments and resources:
Date Name Suggestions

. 2. Services:
Sessions Date of Start of Number of ses- Date of Date of
requested* request sessions sions authorized authorization next review

*Code sessions with a number (number of sessions) and letter: C = Collateral contacts, E = Evaluation, F = Family therapy,
G = Group therapy, I = Individual therapy.

H. Additional comments and information

I. Cooperative treatment planning


Our signatures below mean that we have participated in the formulation of this treatment plan, understand and approve
of it, and accept the responsibility to carry out our parts of the plan fully.

Signature of client (or person acting for client) Date

Signature of service provider Provider number Date

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

This report reflects the patient’s condition at the time of consultation or evaluation. It does not necessarily reflect the patient’s di-
agnosis or condition at any subsequent time.
Progress Note
If a checkbox (❑) is inappropriate or insufficient, enter a letter and write additional comments on a separate page.

A. Client and meeting information


Client: Date:
Meeting #: of authorized on this date with provider #
Meeting was: ❑ Scheduled ❑ Emergency Others present:
Meeting lasted: ❑ 15 ❑ 30 ❑ 45–50 ❑ 60 ❑ 90 ❑ minutes
Client: ❑ Was on time ❑ Was late by min. ❑ Did not show ❑ Cancelled and was rescheduled for
Meeting took place at: ❑ Office ❑ By phone ❑ Clinic ❑ Hospital ❑ Client’s home ❑ Workplace
Mode of treatment: ❑ Individual therapy ❑ Family ❑ Group ❑ Couple ❑ Consultation

B. Topics/themes discussed Notes


❑ Homework assignments
❑ Relationship(s)
❑ Stressors
❑ Identity/role
❑ Work problem
❑ Alcohol/drug problem
❑ Childhood/fam. of origin
❑ Sexual problem
❑ Parenting
❑ Dream(s)
❑ Other

C. Treatments/interventions/techniques
❑ Insights
❑ Behavioral
❑ Cognitive
❑ Homework given
❑ Family
❑ Relationship
❑ Problem solving
❑ Support

(cont.)
FORM 41. Structured progress note form (p. 1 of 2). From The Paper Office. Copyright 2003 by Edward L. Zuckerman.
Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
Progress Note (p. 2 of 2)

D. Assessments
1. Symptoms
Change since last evaluation (enter a check mark)
Current
severity No Less Much im- Resolved/ More Much
Symptom/concern/complaint rating* change severe proved absent severe worse

*Rate from 0 to 10 as follows: 0 = not a problem/resolved; 5 = distressing/limiting; 10 = very severe distress, disruption, harm/risk.

2. Stressors and coping


Current severity Changes in Current level of Changes in Coping skills
Stressor rating* severity? coping/functioning† coping level? employed

*Rate from 0 = not a problem to 10 = very severe, continuous, omnipresent, preoccupying.


†Rate from 0 to 10 as follows: 0 = much less able to cope; 5 = no change from last meeting/evaluation; or 10 = much improved level of coping.

3. Mood: ❑ Normal/euthymic ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric


Affect: ❑ Normal/appropriate ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile
4. Mental status: ❑ Normal ❑ Lessened awareness ❑ Memory deficiencies ❑ Disoriented
❑ Disorganized ❑ Vigilant ❑ Delusional ❑ Hallucinating ❑ Other:
5. Suicide/violence risk: ❑ None ❑ Ideation only ❑ Threat ❑ Gesture ❑ Rehearsal ❑ Attempt
6. Sleep quality: ❑ Normal ❑ Restless/broken ❑ Delayed ❑ Nightmares ❑ Oversleeps
7. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ None ❑ Resistant
8. Treatment compliance: ❑ Full ❑ Partial ❑ Low/noncompliant ❑ Resistant ❑ Denial of disorder
9. Response to treatment: ❑ As expected ❑ Better than expected ❑ Much better ❑ Poorer ❑ Very poor
10. Global Assessment of Functioning (GAF) rating from 100 to 0 is currently:
11. Other observations/evaluations:

E. Changes to diagnoses: ❑ None or

F. Changes to treatment plan: ❑ None or


If treatment was changed, indicate rationale, alternatives considered/rejected/selected in notes.

G. Follow-ups
❑ Next appointment is scheduled for next ❑ week ❑ month ❑ 2 months ❑ 3 months ❑ as needed.
❑ Referral/consultation to: For:
❑ Call/write to: For:

H. Clinician’s signature: Date:

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Termination Summary

Client: Date:
Signature(s) of therapist(s) :

A. Main reason for termination


❑ The planned treatment was completed. ❑ The client refused to receive or participate in services.
❑ The client was unable to afford continued treatment or did not pay bills on time. ❑ Client moved.
❑ There was little or no progress in treatment. ❑ This is a planned pause in treatment.
❑ The client needs services not available here, and so was referred to:
❑ Other:

B. Source of termination decision


The decision to terminate was: ❑ Client-initiated ❑ Therapist-initiated ❑ A mutual decision
❑ MCO-affected ❑ Other:

C. Treatment sessions
Referred on date: Date of first contact: Date of last session:
Number of sessions: Scheduled: Attended: Cancelled: Did not show:

D. Kinds of services rendered


❑ Individual psychotherapy, for sessions ❑ Couple/family therapy, for sessions
❑ Group therapy, for sessions ❑ Other:

E. Treatment goals and outcomes (code outcomes as follows: N = no change, S = some or slight [about 25% to
35%], M = moderate [about 50%], V = very good [about 75% to 100%], E = exceeded expectation)
Goal Outcome

Other notable aspects of treatment outcome,change,or progress:

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

FORM 44. Termination summary form. From The Paper Office. Copyright 2003 by Edward L. Zuckerman. Permission to
photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).