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Assessment and Diagnosis of Depression in Older Adults: A Multidimensional Approach
Instructions
a. Write as an APA paper; a minimum of 5 professional references are required; your textbook is in addition
b. attaching completed assessment scales as appendices (please use the following, Confusion CAM, Geriatric Depression, PHQ9)
Summary and Diagnosis
• SUMMARY OF MENTAL STATUS:
• CLIENT’S STRENGTHS (to assist with achieving treatment goals)
• ASSESSMENT SCALES/INSTRUMENTS: Use minimum 3 assessment scales/instruments (complete diagnostic scale, document expected score & what it means/describes). Describe major purpose of each instrument you used-one paragraphs each scale. Attach completed scales and other information to this assessment as Appendix. 1. PHQ9
2. Confusion CAM
3. Geriatric Depression
• ASSESSMENT & DIAGNOSTIC FORMULATION JUSTIFICATION-Narrative paragraph: Summarize/conceptualize all clinical information to determine the client’s diagnosis and include initial proposal(s) for treatment. Be sure to identify any impairments in life functioning due to the client’s diagnosis (Medical Necessity). Formulation should include risk factors as well as any significant strengths that can assist the client with treatment)
• DIAGNOSTIC DESCRIPTOR (DSM-5): State each diagnostic formulation made as a result of this evaluation. • Give 3-4 differential diagnoses, severity/specifier. State DSM-5 numeric code for each diagnosis. State how you arrived at this diagnosis according to DSM-5 criteria. Include supporting information (V or Z codes as appropriate). Remember to justify all your diagnoses and supporting information. 1. Adjustment disorder 309.28 (F43.23)
2. Depressive Disorder due to Another Medical Condition 293.83 (F06.31) 3. Mild Neurocognitive disorder due to vascular disease 331.83 (G31.84) • ICD-10 Codes: 1. Principal/provisional code: Major Depressive Disorder with mild anxious distress 296.22 (F32.1) V62.89 (Z60.0)
2. Secondary Codes:
3. 4. • TREATMENT GOALS: state 3-4 short-term and long-term treatment goals for this patient. For each, state why the particular goal is appropriate.
• Treatment plan: modality and responsible staff:
• PSYCHOTHERAPY: name 3 modes of psychotherapy that will/should be prescribed for this patient and why. State how you will introduce the idea of this therapy to the patient.
• Disposition/Recommendations/Plan:
• Referrals: List all necessary referral for additional care or assessments, physical and psychiatric. • Follow-up appointment: State when you plan to see this patient for follow-up and why you chose this follow-up interval
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