March 30,2019
A subject that regularly comes up in supervision – at least when clinicians are working under one of the agents of the North Carolina Department of Health and Human Services’ LME/MCOs -is the Comprehensive Clinical Assessment“How do I get it done in the time allotted?” is one of most common questions. Another is “I guess I ended up doing therapy – it seemed the right thing to do – and now I see I missed a lot of detail.”
Assessment is a skilled interview. A skilled conversation. It is not filling in the blanks on a form. It is about establishing a level of trust so that the patient will disclose aspects of themselves, information, history, events, and the like, which they might not disclose to others. It is about your humanity and your “expertness,” including, as part of the latter, a willingness to tactfully probe areas that the patient has not yet decided to disclose, maybe even “wards off” unconsciously. And a sensitivity on your part to know “when not to go there” but also make note of that “not gone into subject” in your documentation so the next clinician is fully informed of your decision, the scope of what you did not investigate, and why you did not. This should be used rarely, and mainly due to lack of time or the issue is or seems to be peripheral to the main issue(s).
In addition a “skilled interview” means interview management. Management of time, inducting the person into the role of “informant” vs “patient” (the interview may be therapeutic, but it is not therapy), the interviewer switching b/t open-ended questions and close-ended questions, giving rationale(s) for different stages of the interview, and sharing the results with the person (family).
An assessment is not a “Level of Care.” I.e., it is not the ASAM, LOCUS, CALOCUS or equivalents. You take the data from the assessment and integrate it into the Level of Care instrument to get an “intensity” of treatment recommendation (s).
An assessment is not in and of itself the use of “tools” such as the following, though these may be involved in the assessment process:
APA DSM-5 Cross-cutting Level 1 measures (adult child/parent versions); APA DSM-5 Level 2 measures; Mini-Mental Status Examination (various versions); Beck Depression Inventory (BDI-II); SASSI-3; PTSD Checklist; Burns Anxiety Inventory; Women’s Complex Trauma Screen; Multimodal Life History Inventory; Addiction Severity Index; Dissociative Experiences Scale (DES); Multidimensional Inventory of Dissociation (MID); Crisis Triage Rating Scale; and Structured Clinical Interview for DSM-IV® Dissociative Disorders (SCID-D-R).
Above all, the skilled assessor knows when to use “key questions” from the above tools or when to use the full tool and/or when to recommend that that full tool be used in a follow-up interview.
[FOR YOUR GENERAL INFORMATION: The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) is the GOLD STANDARD diagnostic exam used to determine Axis I disorders (major mental disorders). The SCID-II is a diagnostic exam used to determine Axis II disorders (personality disorders). An Axis I SCID assessment with a psychiatric patient usually takes between 1 and 2 hours, depending on the complexity of the past psychiatric history and the subject’s ability to clearly describe episodes of current and past symptoms. A SCID with a non-psychiatric patient takes 1/2 hour to 1-1/2 hours. (See editions below.) A SCID-II personality assessment takes about 1/2 to 1 hour.]
General comments on writing the assessment and subsequent documentation: The Golden Thread:
- Chief complaint is usually a quote.
- The assessment is specific.
- The assessment, especially the diagnostic formulation, needs concrete examples
- Ex: You need 6 criteria for ADHD subtypes, therefore six examples.
- Simplify as much as possible without missing the point.
- No vagueness or lofty goals.
- Concrete language overall.
- Short punchy sentences whenever possible.
- Prune back sentences that have 2-3 verbs, extra adverbs and adjectives and multiple commas.
- Ask yourself:
- Am I using psychiatric/psychological terminology correctly?
- In all other ways – when psychiatric/psychological terminology is not needed:
- Would my patient (or patient’s parents) understand this easily OR with minimum explanation?
- Would they agree with the facts I have listed?
- And would it make sense to them (if not right away, after I gave a simple explanation).
- And will the doctor find it useful?
- And will another reviewer find it clear and understandable – an auditor, or, if we have a third party (another agency) request our documentation, that they will?
Summarizing.
Formulating the case is allowed. It if you know how to do that using a specific model such as Cognitive Behavioral Therapy or Structural Family Therapy, etc.
Formulation is not your OPINIONS or guesses. Ex. “I think the patient…..”
Recommendations for treatment should be well justified.
If you are “just” the assessor and the case will be forwarded to others to handle the treatment, the final written product should remove any need for the outpatient therapist or teams to re-do your assessment EXCEPT where you have indicated a subject needed further investigation.
The final written product should be so clear that the clinician / QP for OPT, IIH, CST, etc can directly ‘cut and paste’ your observations/summaries etc into the Person Centered Plan and the Treatment Authorization Request. NOTE: But that is about the limit for cutting and pasting, which should otherwise be avoided.
STANDARD ENGLISH: Spelling, syntax and grammar count. Changes in tense should be clear. Build paragraphs with related material.
NARRATIVE: When explaining any complex social interaction, the use of multiple “he” and “she” should not confuse the reader. Otherwise, while it is cumbersome, you should use names:
Example (Confusing) Sally (Pt) reports that she has trouble with her mother. When she says “You’re not fair,” they get in an argument. [Which she? Mom or Sally?]
Example (Clear) Sally reports that she has trouble with her mother, When Sally says “You’re not fair,” they get in an argument.