Current through Register Vol. 51, page 43, September 23, 2024
(1) A diagnostic assessment must be completed
within 30 days of the recipient's first face-to-face or telehealth visit with a
mental health provider. On-going assessment and identification of changes in
the recipient's needs and strengths must occur throughout treatment and must be
documented in progress notes or other clinical documentation. Three
face-to-face or telehealth interviews designed to assist in the formulation of
a diagnostic assessment are covered. For children under 18 years of age, the
mental health staff shall obtain permission from the parent or legal guardian
to meet with the child, and at least one parent or legal guardian shall
participate in the assessment. Psychiatric therapeutic procedures or
psychiatric somatotherapy provided before the diagnostic assessment is
completed are considered noncovered services.
(2) A diagnostic assessment must include all
of the following components:
(a) A
face-to-face or telehealth interview with the recipient;
(b) Identification of the strengths of the
recipient and the recipient's family, if appropriate, previous periods of
success and the strengths that contributed to that success, and potential
resources within the family, if applicable;
(c) Presenting problems or issues that
indicate a need for mental health services;
(d) Identification of readiness for change
for problem areas, including motivation and supports for making such
changes;
(e) Relevant family
history, including family relationship dynamics and family psychiatric and
substance abuse history;
(f)
Behavioral observations and an examination of the recipient's mental status,
including a description of anomalies in the recipient's appearance, general
behavior, motor activity, speech, alertness, mood, cognitive functioning, and
attitude toward the symptoms;
(g)
Current substance use and relevant treatment history, including attention to
previous mental health and substance use disorder or gambling treatment and
periods of success, psychiatric hospital admissions, psychotropic and other
medications, relapse history or potential for relapse, physical illness, and
hospitalization;
(h) A review of
the records that pertain to the recipient's medical and social background and
history, if available;
(i) Contact
with the recipient's relatives and significant others to the extent necessary
to complete an accurate psychological evaluation for the purpose of writing the
assessment report and developing the treatment plan; and
(j) Formulation of a diagnosis that is
consistent with the findings of the evaluation of the recipient's condition,
including documentation of co-occurring medical, developmental disability,
mental health, substance use disorder or gambling issues, or a combination of
these based on the diagnostic evaluation.
(3) A diagnostic assessment must include the
following components, if applicable:
(a)
Educational history and needs;
(b)
Legal issues;
(c) Living
environment or housing;
(d) Safety
needs and risks with regard to physical acting out, health conditions, acute
intoxication, or risk of withdrawal;
(e) Past or current indications of trauma,
domestic violence, or both; and
(f)
Vocational and financial history and needs.
(4) The mental health provider must complete,
sign, and date the diagnostic assessment before providing mental health
treatment. The signature is a certification by the mental health provider that
the findings of the diagnostic assessment are accurate. The certification date
is the effective date of the diagnostic assessment.
Clinical record requirements, §
67:16:41:08.
