My agency requires assigning a diagnosis after the first session, and this is very hard to do.  How can I give a diagnosis to my client when I don’t have complete information about them?

This agency requirement is probably related to third party billing and the need to document the medical necessity of the services you are providing to the client. While this requirement ensures that your clients have access to the services they need, it can be frustrating as a clinician to assign a diagnosis when you haven’t had a chance to develop a comprehensive understanding of their symptoms. I will suggest a couple of strategies regarding the notation of the diagnosis itself that may alleviate your concern and then  outline a three-step process for arriving at a diagnosis after the first session or after a more thorough assessment.  My comments are based on using the DSM-5, and may need to be adapted if your agency is using the DSM-IV.

One strategy is to check with your supervisor or the billing manager about the use of diagnoses marked “Provisional” when you have incomplete information.  If this is allowed by the third party, it is a way to acknowledge that your diagnosis is tentative.  Situations in which a “provisional” diagnosis are appropriate are when you know a client meets most of the criteria but haven’t confirmed the full set of criteria required for the diagnosis or when the client reports a diagnosis given by another health care provider that you haven’t verified independently. Also ask about the use of “Other Specified” and “Unspecified” diagnoses when you have determined which category the client’s symptoms fit but don’t know whether they meet the criteria for a specific diagnosis within that category.  These diagnoses are often useful when your information is incomplete, if they are acceptable to the third party.

A second aspect of diagnosis that may alleviate some of your concern is to view diagnosis as an ongoing process rather than a decision that is made once for the duration of the client’s treatment. The diagnosis you assign after the first session may not be the diagnosis that accurately reflects the client’s history and symptoms that emerge as you complete an assessment. This will be most likely if you have used “provisional,” “other specified,” or “unspecified” in your diagnosis, but there are other times when the client’s initial presentation differs from the impression you get after four to six more sessions. I also suggest reviewing the diagnosis every six months or whenever you update the treatment plan. This allows you to update the diagnosis if appropriate, to reflect changes in the client’s symptoms or new historical information you have learned.

I have developed a three-step process to help new clinicians develop a diagnosis, and the worksheet reflecting this process is available for download in an online workbook. I find that new clinicians often have difficulty prioritizing the different pieces of information they have about clients, and this leads to confusion in identifying the most accurate diagnosis. A more detailed description of the diagnostic process is contained in Chapter 5 of my book, available through Amazon or Routledge.

My recommendation is to begin by listing the client’s current symptoms and past symptoms reported as part of the history. This ensures that you consider all of the data that is relevant to the client’s diagnosis rather than prematurely focusing on one aspect of the presentation that may lead to an inaccurate diagnosis or may neglect a secondary diagnosis that is clinically important.

Second, make note of the categories in the DSM-5 that fit your client’s symptoms, being as comprehensive as possible.  In the worksheet, I suggest that you note the categories in which symptoms are present (or are part of the history) and then note whether these symptoms are relevant to the current treatment, i.e., part of the reason for the client seeking treatment. This notation will serve as a reminder to address the relevant symptoms in your treatment goals.  Remember to include the “Other Conditions” category if your client has psychosocial stressors, relationship difficulties, or a history of trauma.

The third step is to look at the specific diagnoses within the categories you have noted to see whether your client’s symptoms meet the criteria for one or more diagnoses. If you noted the “Other Conditions” category, review these codes to determine which situational factors are important to include in your diagnosis. Often, your client’s clinical presentation may be best described by one or more diagnoses and one or more Z codes.  If this is the case, choose the diagnosis that best represents the reason for treatment as the primary diagnosis which will be reported for billing purposes. The other diagnoses will be included in your assessment to provide a comprehensive view of the client’s symptoms, history, and current psychosocial stressors.

I hope you find these comments helpful in working with DSM-5 and diagnosis. Please email me with comments, questions, or suggestions for future blog topics.