DSM-5-TR Diagnosis (H3)
Does the case meet the criteria for a disorder within the DSM-5-TR?
The justification should begin with “Client X”’s presentation meets the diagnostic criteria for _____ as evidenced by…” with a subsequent description of all diagnostic criteria that warrant the diagnosis
Identify specific information from the case to justify applicable diagnostic criteria
All applicable diagnostic criteria must be supported
Identify all applicable subtypes and specifiers
Include the corresponding ICD (F) code
Provide at least one other condition that may be a focus of clinical attention with the corresponding ICD code
Psychosocial Issues
What are the psychosocial issues facing the client?
Extrapolate and expand upon identified psychosocial issues that could exacerbate the client’s illness or adversely impact treatment
Identify cultural considerations specific to the client
Client’s Strengths/Protective Factors
What strengths/protective factors does the client possess (such as internal and external strengths) that may contribute to treatment success?
Areas of Further Assessment
What areas require further investigation to enhance a clinical picture?
Identify aspects of the client’s presentation, history, current circumstances, symptomatology, etc., requiring further exploration
Include a rationale for further assessment
Such as why further assessment is important and what relevant information it may provide
Include at least one validated screening tool that will either: confirm a diagnosis, rule out a diagnosis, or explore the possibility of a potential co-occurring diagnosis
Provide a rationale for the use of the chosen screening tool
Initial Treatment Plan
What initial treatment goals specific to the client presentation and diagnosis are appropriate to employ?
Identify at least 3 client objectives specific to presentation and diagnosis that are:
Evidence-based and specific to the diagnosis (indicating a client is to engage in therapy is vague and generic)
Culled from a literature review (such as from a professional, peer-reviewed journal and/or primary, peer-reviewed text)
The literature cited must be published within the last 10 years
Reference no fewer than 2 primary sources
Make sure the literature review is from a primary source–evidence-based treatment is NOT obtained via a secondary source (such as a website referencing a primary source, a self-help book, social media website, etc.)
— I am including the case review attachment and an example that was provided to us.
