- You must support your diagnoses: what symptoms do you see evidence of that are consistent with your impression? Remember: “as manifested by”
- You may add a note accounting for your choices or addressing unresolved issues/problems
- If you need 6 and only see 5, add “Provisional” to classification
- If I can’t read it; it doesn’t count. If you have any question regarding the legibility of your handwriting–print, or consider typing/word processing your responses. Bad handwriting is more than annoying in case notes, etc.–it may be viewed evidence of failing to meet the standard of care. In general: print out your responses (remember: old, grumpy professors should be hummored)
- How much can you explain with your primary diagnosis? Are additional diagnoses needed?
- You only need to add “Primary Diagnosis/Reason For Visit” if 1) there is more than one diagnosis and 2) you are considering something other than your first dx as the primary: the assumption is that your first diagnosis is your Primary/Reason For Visit unless you indicate something else.
- ADHD: DSM-IV and IV-TR joined the rest of the world (i.e., ICD-9, ICD-9-CM, and ICD-10) in adopting a “pervasive” criterion for ADHD–there must be evidence of ADHD in at least two settings (DSM-III & III-R were “situational”–ADHD could be diagnosed based on data from only one setting). We are not told what count’s for a setting. Reviewing the text and “official” casebooks suggests:
- home and school are definitely two settings
- home and your office are two settings
- home and community (neighborhood, your office, grocery store) are two settings
- neighborhood and store are probably two settings
- classroom and school playground are probably two settings
- Ms. Sletkey’s class and Mr. Jordan’s class might be two settings
- home and grandparents might be two settings
- bedtime at home and bathtime at home are probably not two settings (although a functional behavioral analysis might support their being considered two different environments)
note: many/most DSM-5 diagnoses are situational, including ODD and CD (you only need evidence from one setting)