Hello,
I am in need of some assistance and feedback on the best way to set up a snippet for treatment plans for my healthcare practice.
Summary
- I am looking to create a treatment plan snippet.
- This snippet will be used to complete a Google Form.
- Each selection will be inserted into different questions on the form.
(I will use a note to display this information)
Using DSM-5/ICD-9-CMIICD-10-CM:
ICD-9-CM ICD-10-CM DSM-5 Disorder, Condition, or Problem 300.02 F41.1 Generalized Anxiety Disorder 300.09 F41.8 Other Specified Anxiety Disorder 300.00 F41.9 Unspecified Anxiety Disorder 309.24 F43.22 Adjustment Disorder, With Anxiety
BEHAVIORAL DEFINITIONS
- Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a number of events or activities.
- Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
- Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
- Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying asleep, exhibiting a general state of irritability).
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*Section headers will be displayed through a note)
(Plan to us dropdown for this section)
LONG-TERM GOALS
- Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.
- Stabilize anxiety level while increasing ability to function on a daily basis.
- Resolve the core conflict that is the source of anxiety.
- Enhance ability to effectively cope with the full variety of life's worries and anxieties.
- Learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning.
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(Unsure how to set up a workflow to show only associated therapeutic interventions after selecting short-term objectives)
SHORT-TERM OBJECTIVES
- Describe situations, thoughts, feelings, and actions associated with anxieties and worries, their impact on functioning, and attempts to resolve them. (1, 2)
- Complete psychological tests designed to assess worry and anxiety symptoms. (3)
- Complete a medical evaluation to assess for possible contribution of medical or substance-related conditions to the anxiety. (4)
- Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (5, 6, 7, 8)
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THERAPEUTIC INTERVENTIONS
- Focus on developing a level of trust with the client; provide support and empathy to encourage the client to feel safe in expressing his/her GAD symptoms.
- Ask the client to describe his/her past experiences of anxiety and their impact on functioning; assess the focus, excessiveness, and uncontrollability of the worry and the type, frequency, intensity, and duration of his/her anxiety symptoms (consider using a structured interview such as The Anxiety Disorders Interview Schedule-Adult Version).
- Administer psychological tests or objective measures to help assess the nature and degree of the client's worry and anxiety and their impact on functioning (e.g., The Penn State Worry Questionnaire; 0Q-45.2; the Symptom Checklist-90-R.
- Refer the client to a physician for a medical evaluation to rule out general medical or substance-related causes of the GAD.
- Assess the client's level of insight (syntonic versus dystonic) toward the "presenting problems" (e.g., demonstrates good insight into the problematic nature of the "described behavior," agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the "problem described" and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the "problem described," is not concerned, and has no motivation to change).
- Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
- Assess for any issues of age, gender, or culture that could help explain the client's currently defined "problem behavior" and factors that could offer a better understanding of the client's behavior.Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
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Thank you in advance for your feedback and help!
-Ed
