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Patient Assessment Paper

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Assessment and Diagnosis Journey’s intake unit completes all initial assessment to assess client for different level of care and accurately assign them to the most appropriate unit. The different level of care ranged from intensive inpatient care unit to medication only. As a practicum student, I worked in the outpatient services unit. The assessment was completed via an online program with an intake staff and the client, usually a week or two before the first scheduled appointment with a clinician. Therefore, once a client is assigned to me, I have access to review their file. The assessment are usually completed in a brief model format, and as the clinician assigned to work with a client, I am expected to use the first two sessions of therapy…show more content…
Since being seen at Journey starting in 2011, Lucy has had the same diagnoses with the exception of her first time at Journey, where she was diagnosed with Adjustment Disorder with Mixed Anxiety and Depressed Mood. However, that diagnosis was dropped when she came back in 2012. She is currently prescribed Wellbutrin for mood, Gabapentin for anxious symptoms, Trazodone for mood and anxious symptoms, and Zoloft for obsessive-compulsive symptoms by her primarily care provide in a community clinic. Journey does not have additional assessment measures to assist in further diagnostic evaluation. Also, the clinician Lucy was working with is no longer an employee of the agency, which prevents opportunity to consult. Therefore, the diagnoses are based on my clinical assessment and my supervisor’s input. Based upon Lucy’s self-report, our interactions, and my on-going assessment, I have decided to maintain some of Lucy’s initial diagnoses with the addition of a V code. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM; 2013), Lucy was diagnosed with the following
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