DSM-5 is a
nonaxial diagnosis system
what 4 things do you list first in diagnosis
- clinical disorders 2. personality disorders 3. ID 4. general med conditions
what do you list second in a diagnosis?
psychosocial and environmental problems
what do you list 3rd in a diagnosis?
global measure of disability (WHODAS)
what 5 other things should be considered in the treatment section?
- take care recommending treatment outward your area of practice 2. placement/alteration in environment 3. further investigation I.e med testing 4. self-help (support groups) 5. other (drivers license, capacity to care for kids)
in the test results section of a report what type of scores do your report?
standardised scores, percentages and percentiles with a description I.e below average, average etc
the psychologist must report back to the referrer under these 3 circumstances for Medicare reasons
- completion of initial course of treatment (Max 6 services) 2. on completion of any subsequent course of treatment which forms the end of an episode of treatment 3. if an individual does not complete treatment (stops attending after 2 sessions)
first 4 points to note on a clients presentation:
- arrived on-time/late/early 2. orientated to time place person, attention span? 3. physical presentation 4. mobilisation/gait
next 4 points of a clients presentation
- speech 6. mood 7. level of engagement and effort 8.interaction and insight
what are the 5 words used when constructing good session notes?
why, when, where, who, what
what are process notes?
personal reflections on therapeutic relationship or process. subjective thoughts and reflections.
why are process notes problematic?
they cannot be validated or challenged in a legal setting
how long do you keep records of an adult for?
7years
how long do you keep records of a child for?
until at least 25 years
