Recommendations Explain any recommendations for interventions, treatment, and/or disposition.Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case.
Explain any recommendations for interventions, treatment, and/or disposition.
2. Clinical Impression (Diagnosis)
Write the clinical impression in the DSM-5 format:
XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).
(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)
OTHER FACTORS:
Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.
3. Recommendations
Explain any recommendations for interventions, treatment, and/or disposition.
4. Questions
Address the specific questions that were asked in the instructions for this assignment.
Here is a sample assignment question and an appropriate brief response:
Provide a brief description of what you have learned about the individual reviewed in the nursing field. Include information about the individual in terms of demographics and general history, and the sources of that information, and the reason that the individual was referred, and by whom.
Provide any information you may have about evaluations that have been conducted, including the results.
Question: Describe what further information you would need to accurately diagnose this case.
Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to
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