Assignment Prompt & Instructions
[>Sociology homework help](https://www.sweetstudy.com/fields/social-science-sociology)
Please see attached file
**files (6)**
– ## SOCW6090_W03_RedFlags_KeyWords.pdf
– ## SOCW6090_W03_Diagnosis_Assignment_Tips.pdf
– ## casestudy.docx
– ## Other_Specified_and_Unspecified_Diagnosis-220725_Transcript.pdf
– ## SOCW6090_W03_How_to_Write_Diagnosis_DSM5TR.pdf
– DiagnosisofNeurodevelopmentaland.docx
**## SOCW6090_W03_RedFlags_KeyWords.pdf**
© 2022 Walden University, LLC
Red Flags and Their Key Words
When evaluating clients, be aware of what is being said, what is unspoken, and any
nonverbal messages the client is sending. There are certain words mentioned by a
client that may lead you to evaluate for certain disorders first, and then followed by
evaluating the differential diagnosis. Below are some words—i.e., “red flags”—to help
you evaluate for certain disorders. You still need to be open to other possibilities, but
this will give you a place to start.
Schizophrenia and Other Psychotic
Disorders
I hear people talking to me.
They are telling me . . .
They are after me.
Client’s speech does not make sense.
Bipolar I’m on top of the world.
I bought all this stuff.
I do not need much sleep.
Client’s speech is very fast
Depressive Disorders I am depressed.
I do not want to go out anymore.
I do not want to wake up.
I cannot sleep. I am so tired.
I gained weight recently.
I lost weight recently.
I cannot concentrate.
Anxiety Disorders I worry about everything.
I am up at night thinking.
I have anxiety attacks.
I panicked out of nowhere.
Obsessive compulsive disorders I worry about the dirt in my house.
My thoughts go round and round.
I do repetitive behaviors.
I have repetitive thoughts.
Trauma and Stressor-Related Disorders I am easily startled.
I have nightmares.
I do not want to talk about the situation.
I no longer go to those places.
I avoid those people.
Dissociative Disorders I have gaps in my memory.
“We”. . .
“They”. . .
**## SOCW6090_W03_Diagnosis_Assignment_Tips.pdf**
© 2022 Walden University, LLC
Tips and Guidelines for Practice Diagnosis in This Course
Consider printing this tip sheet. Keep it next to you as you work through each practice
diagnosis.
Remember: After the intake assessment, you must make a diagnosis. In this course,
the details you would normally observe and assess are found in the written case study
that you read. With the case studies, apply the criteria in an applicable assessment
measure to gauge symptoms and severity based on details in a case study.
Also, utilize the resources in the course, such as the American Psychiatric Association’s
Online Assessment Measures (see the online classroom for the most up-to-date link).
For these, you would use an applicable questionnaire to guide an interview and follow
the guidance within each assessment measure.
When diagnosing, place the diagnosis (i.e., the diagnostic code—F followed by the
number and disorder name) before your summary. It must look like this:
F33.3 Major depressive disorder, recurrent episode, with psychotic features
F42 Obsessive-compulsive disorder, with poor insight
F10.20 Alcohol use disorder, in sustained remission
Z56.9 Other problem related to employment
Z60.9 Unspecified problem related to social environment
Other Tips
1. ICD 10 codes MUST be used (e.g., F60.90).
2. Z codes must be added. These are psychosocial and environmental stressors
impacting the case over the last 12 months.
3. Cases may include any diagnoses previously covered in earlier weeks.
4. Look for all possible diagnoses for the case, not just those related to the readings
for the week.
o No cases will include diagnoses that have not been covered in earlier
weeks.
5. Differential diagnosis means the case has similar symptoms—it does not mean
compare any case in the DSM-5-TR.
6. When explaining your decision in the summary portion please include the criteria
in the case that refer to the symptoms you are noting.
7. Read the directions in the course.
**## casestudy.docx**
**Week 3: Case assignment**
**CASE of OMARI**
**INTAKE DATE: May xxxx**
**IDENTIFYING/DEMOGRAPHIC DATA:** Omari is a 10-year-old male in the third grade. He lives in Houston, Texas with his parents. He is the only child of parents who have completed post-graduate education. The family is from St. Lucia and relocated to the United States when Omari was 6 months old for job opportunities. Omari is an intelligent young boy who presents with significant potential to excel academically.
**CHIEF COMPLAINT/PRESENTING PROBLEM:** Omari was referred for an evaluation because
his parents and teacher indicate that Omari is restless and often requires reminders to help him stay on task. Omari has difficulty focusing on and sitting still in class. He is described as "constantly running around" and presented with difficulties listening and following instructions. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior.
**HISTORY OF PRESENT ILLNESS:** Omari enjoys spending time with his friends. Most recently Omari was found in a neighbor’s house that he broke into.
The friend group recently found fires in the woods and neighbors called the police. While Omari interacts well with peers about his own age, his parents believe he is easily led and influenced by others. Omari does get upset when he does not receive what he wants and acts out, forcing others to give things to him. He physically and verbally fights with his peers when this happens but then he gets back hanging around with his friends.
Omari can 'hyper focus' on some activities of interest, however he often has difficulty sustaining his attention at school. Omari has been known to blurt out answers and interrupts other students in the classroom. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. He is easily frustrated and emotionally impulsive and has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in first and second grades.
**PAST PSYCHIATRIC HISTORY:** This is the first evaluation for Omari.
**SUBSTANCE USE HISTORY:** Omari denies any substance use.
**PAST MEDICAL HISTORY:** Omari has had normal childhood illnesses. He has had all vaccinations.
**FAMILY MEDICAL AND PSYCHIATRIC HISTORY:** Omari’s parents deny any psychiatric family history. There were noted medical histories from the family. The family living in St. Lucia has a different perspective of medical and psychiatric illness than those living in the United States. They believe in more natural intervention for illnesses.
**MENTAL STATUS EXAM:** Omari is dressed appropriately and looks like his stated age. At times during the interview, he would become frustrated and want to leave. Omari was oriented to time, place and person. Omari was able to repeat the words given to him. He denied suicide and homicide ideation.
**## Other_Specified_and_Unspecified_Diagnosis-220725_Transcript.pdf**
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 1
Other Specified and Unspecified Diagnosis
Program Transcript
NARRATOR: You gather information from a client to diagnose during an intake. What
happens if the client does not meet the required symptoms to make the diagnosis? It
might have feeling tentative about what to diagnose. You may have heard or seen
tentative, provisional, or rule-out diagnoses. Those terms may describe your
uncertainty, but do they have a place and a diagnosis?
The answer is a simple no for social workers. Some agencies utilize these terms after
they code a diagnosis. Although, for best practice, you are strongly advised to avoid
them. You'll see why soon. But first, let's focus on the best practice, using other
specified or unspecified.
In real-world settings, be prepared for clients who do not meet every required symptom
of a disorder. A client may arrive with depression, lethargic, and experiencing a loss of
pleasure or interest. They report a diminished ability to concentrate. These are some
criteria for major depressive disorder. But to diagnose a depressive episode, you need
five of the nine listed symptoms. And right now, you only have three. At this point, you
cannot legitimately diagnose major depressive disorder.
Still, your detective skills point you strongly in this direction. How do you diagnose? In
every category of the DSM-5-TR, there are two options called other specified and
unspecified disorders. Both mean the client does not meet the full criteria for a disorder.
First, let's explore other specified disorder, which means the client is suspected to be in
this category, but the full criteria are not met, despite showing some symptoms. You are
diagnosing this fact and documenting the reason for the full disorder is not met, in this
case, not meeting five out of the nine symptoms. You must record the name of the
category followed by the specific reasons. F32.89 is the code for other specified
depressive disorder followed by a comma, followed by the reason why they don't meet
the criteria.
You can also use unspecified disorder, also an option in every category. Here, you do
not need to say why certain criteria are not met, while still recording a diagnosis that is
acceptable. Note that the number code is different in each of these. These are
legitimate diagnoses, and they are covered by insurance.
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 2
Why should you not use tentative, provisional, or a rule-out diagnosis when you don't
have all the criteria, even if an agency would allow it? There is no code that
corresponds to the words tentative, provisional, or rule out. Using these as if they are
implied from codes, is essentially saying the client meets the criteria for a disorder.
Note the difference between the provisional code and the other specified code. One
code records a specific disorder that may not be present. It may be recorded on records
without the provisional noted, which could be confusing or ultimately inaccurate. When
the code is submitted to insurance companies, there is not a spot for the word
provisional, and sometimes just the code itself may appear on a form. So the insurance
accepts this as the client's diagnosis when they never fully met the criteria, except, as
we noted, we're not fully sure it's major depressive disorder yet.
The other specified code is in its own unique code that accounts for how the client
actually presents. Using other specified and unspecified diagnoses are the best ways to
still work within the parameters of proper diagnoses, but account for the reality of a
complex process. They allow you to be accurate while you continue evaluating the client
for the best treatment.
**## SOCW6090_W03_How_to_Write_Diagnosis_DSM5TR.pdf**
© 2022 Walden University, LLC 1
How to Write a Diagnosis According to the DSM-5-TR
Writing a Diagnosis
A diagnosis is written as a simple list in order of priority to the current treatment
needs. For example:
F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern
F41.1 Generalized anxiety disorder
Z60.3 Acculturation difficulty
Note: Each diagnosis needs a code that is written before the name of the diagnosis.
How to Code
A diagnostic code, even when using the DSM-5-TR, follows the ICD-10 code
structure. The code structure is between three (3) and seven (7) characters. The
figure below shows how each digit in the code is organized.
Alpha
(Not U) Numeric Characters 3–7 can be any combination
of alpha or numeric
1st
digit
2nd
digit
3rd
digit • 4th
digit
5th
digit
6th
digit
7th
digit
Category Etiology, anatomical site, severity Extension
For mental health conditions, codes always start with a letter F, followed by two to six
(2– 6) digits. A code is not valid unless it has been coded to the full number of
digits required.
A code with only the first three digits is used only if that condition is not further
subdivided within the DSM-5-TR. For example, for schizophrenia, there are no
additional characters in Spaces 4, 5, 6, and 7.
F20.9 Schizophrenia
In other cases, numbers must be added in the 4th, 5th, or 6th spaces to individualize
a condition. Spaces 4–6 provide greater detail of causes and severity. For example,
here are two codes for mania:
F31.11 Bipolar I disorder, current episode manic, mild
2
F31.13 Bipolar I disorder, current episode manic, severe
Many disorders have more than one ICD code when there are common and clearly
identified subtypes to the illness. The diagnostic criteria box always tells you if a
code must be subdivided.
If you do not see a code at the top of the diagnostic criteria box, look for the correct
codes at the bottom of the box. Often the box prompts for further individualization by
saying “Specify if” or “Specify whether.” You may also be asked to set a severity
level.
The wording “specify whether” tells you that the subtypes that follow are mutually
exclusive.
For example, here are two subtypes for schizoaffective disorder:
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
Always check for coding notes for further directions. For example, in addition to
our subtypes for schizoaffective disorder, if catatonia is present, an additional code is
found in the coding note.
Coding note: Include the name of the medical condition in the name of the
mental disorder (e.g., F06.1 catatonic disorder due to hepatic encephalopathy).
The other medical condition should be coded and listed separately immediately
before the catatonic disorder due to the medical condition (e.g., K72.90 hepatic
encephalopathy; F06.1 catatonic disorder due to hepatic encephalopathy).
Now the diagnosis looks like this:
F25.0 Schizoaffective disorder, bipolar type
F06.1 Catatonia (associated with another mental disorder)
Some disorders, such as the substance/medication-induced disorders, have more
complex codes for their subtypes. When this happens, there is always a table and a
coding note found at the bottom of the diagnostic criteria box.
How to List Multiple Codes
Formal DSM-5-TR diagnosis combines into one list all relevant mental disorders,
including personality disorders. The DSM-5-TR also expands the psychosocial
stressors that a patient might be experiencing. These are called “Other conditions
that may be a focus of clinical attention” and most begin with the letter “Z.”
© 2022 Walden University, LLC
© 2022 Walden University, LLC 3
These conditions, which are critical to psychosocial treatment, are found near the
end of the manual.
In a diagnostic list, always place the principal diagnosis first (the reason for the
visit, if in an outpatient setting). Other mental health comorbid diagnoses follow in
order of priority to the treatment or focus of attention.
RULE A: In this diagnostic list, a mental disorder was the reason for the visit.
Other psychosocial factors relevant to the service are listed after mental health
conditions
F40.00 Agoraphobia
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
The order of priority above is (a) principal mental health diagnosis, (b)
psychosocial needs.
RULE B: If the client above has a clinical diagnosis of a mental health problem
as the principal diagnosis (all F codes), with the presence of a second, the
diagnosis looks like this:
F40.00 Agoraphobia
F50.01 Anorexia nervosa, restricting subtype
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
© 2022 Walden University, LLC 4
References
American Psychiatric Association. (2022a). Diagnostic and statistical manual of mental
disorders (DSM-5-TR) (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787
American Psychiatric Association. (2022b). DSM-5-TR online assessment measures.
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-
resources/assessment-measures
Centers for Disease Control and Prevention. (2017). ICD-10-CM official guidelines for
coding and reporting: FY 2017 (October 1, 2016–September 30, 2017).
https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
Centers for Disease Control and Prevention. (2022). International classification of
diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from
https://www.cdc.gov/nchs/icd/icd-10-cm.htm
CMS.gov. (2021). Provider resources.
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources
World Health Organization. (2022). ICD-11: International classification of diseases for
mortality and morbidity statistics: Reference guide (11th ed.).
https://icdcdn.who.int/icd11referenceguide/en/html/index.html
**DiagnosisofNeurodevelopmentaland.docx**
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**DiagnosisofNeurodevelopmentaland.docx**
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**## SOCW6090_W03_RedFlags_KeyWords.pdf**
© 2022 Walden University, LLC
Red Flags and Their Key Words
When evaluating clients, be aware of what is being said, what is unspoken, and any
nonverbal messages the client is sending. There are certain words mentioned by a
client that may lead you to evaluate for certain disorders first, and then followed by
evaluating the differential diagnosis. Below are some words—i.e., “red flags”—to help
you evaluate for certain disorders. You still need to be open to other possibilities, but
this will give you a place to start.
Schizophrenia and Other Psychotic
Disorders
I hear people talking to me.
They are telling me . . .
They are after me.
Client’s speech does not make sense.
Bipolar I’m on top of the world.
I bought all this stuff.
I do not need much sleep.
Client’s speech is very fast
Depressive Disorders I am depressed.
I do not want to go out anymore.
I do not want to wake up.
I cannot sleep. I am so tired.
I gained weight recently.
I lost weight recently.
I cannot concentrate.
Anxiety Disorders I worry about everything.
I am up at night thinking.
I have anxiety attacks.
I panicked out of nowhere.
Obsessive compulsive disorders I worry about the dirt in my house.
My thoughts go round and round.
I do repetitive behaviors.
I have repetitive thoughts.
Trauma and Stressor-Related Disorders I am easily startled.
I have nightmares.
I do not want to talk about the situation.
I no longer go to those places.
I avoid those people.
Dissociative Disorders I have gaps in my memory.
“We”. . .
“They”. . .
**## SOCW6090_W03_Diagnosis_Assignment_Tips.pdf**
© 2022 Walden University, LLC
Tips and Guidelines for Practice Diagnosis in This Course
Consider printing this tip sheet. Keep it next to you as you work through each practice
diagnosis.
Remember: After the intake assessment, you must make a diagnosis. In this course,
the details you would normally observe and assess are found in the written case study
that you read. With the case studies, apply the criteria in an applicable assessment
measure to gauge symptoms and severity based on details in a case study.
Also, utilize the resources in the course, such as the American Psychiatric Association’s
Online Assessment Measures (see the online classroom for the most up-to-date link).
For these, you would use an applicable questionnaire to guide an interview and follow
the guidance within each assessment measure.
When diagnosing, place the diagnosis (i.e., the diagnostic code—F followed by the
number and disorder name) before your summary. It must look like this:
F33.3 Major depressive disorder, recurrent episode, with psychotic features
F42 Obsessive-compulsive disorder, with poor insight
F10.20 Alcohol use disorder, in sustained remission
Z56.9 Other problem related to employment
Z60.9 Unspecified problem related to social environment
Other Tips
1. ICD 10 codes MUST be used (e.g., F60.90).
2. Z codes must be added. These are psychosocial and environmental stressors
impacting the case over the last 12 months.
3. Cases may include any diagnoses previously covered in earlier weeks.
4. Look for all possible diagnoses for the case, not just those related to the readings
for the week.
o No cases will include diagnoses that have not been covered in earlier
weeks.
5. Differential diagnosis means the case has similar symptoms—it does not mean
compare any case in the DSM-5-TR.
6. When explaining your decision in the summary portion please include the criteria
in the case that refer to the symptoms you are noting.
7. Read the directions in the course.
**## casestudy.docx**
**Week 3: Case assignment**
**CASE of OMARI**
**INTAKE DATE: May xxxx**
**IDENTIFYING/DEMOGRAPHIC DATA:** Omari is a 10-year-old male in the third grade. He lives in Houston, Texas with his parents. He is the only child of parents who have completed post-graduate education. The family is from St. Lucia and relocated to the United States when Omari was 6 months old for job opportunities. Omari is an intelligent young boy who presents with significant potential to excel academically.
**CHIEF COMPLAINT/PRESENTING PROBLEM:** Omari was referred for an evaluation because
his parents and teacher indicate that Omari is restless and often requires reminders to help him stay on task. Omari has difficulty focusing on and sitting still in class. He is described as "constantly running around" and presented with difficulties listening and following instructions. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior.
**HISTORY OF PRESENT ILLNESS:** Omari enjoys spending time with his friends. Most recently Omari was found in a neighbor’s house that he broke into.
The friend group recently found fires in the woods and neighbors called the police. While Omari interacts well with peers about his own age, his parents believe he is easily led and influenced by others. Omari does get upset when he does not receive what he wants and acts out, forcing others to give things to him. He physically and verbally fights with his peers when this happens but then he gets back hanging around with his friends.
Omari can 'hyper focus' on some activities of interest, however he often has difficulty sustaining his attention at school. Omari has been known to blurt out answers and interrupts other students in the classroom. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. He is easily frustrated and emotionally impulsive and has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in first and second grades.
**PAST PSYCHIATRIC HISTORY:** This is the first evaluation for Omari.
**SUBSTANCE USE HISTORY:** Omari denies any substance use.
**PAST MEDICAL HISTORY:** Omari has had normal childhood illnesses. He has had all vaccinations.
**FAMILY MEDICAL AND PSYCHIATRIC HISTORY:** Omari’s parents deny any psychiatric family history. There were noted medical histories from the family. The family living in St. Lucia has a different perspective of medical and psychiatric illness than those living in the United States. They believe in more natural intervention for illnesses.
**MENTAL STATUS EXAM:** Omari is dressed appropriately and looks like his stated age. At times during the interview, he would become frustrated and want to leave. Omari was oriented to time, place and person. Omari was able to repeat the words given to him. He denied suicide and homicide ideation.
**## Other_Specified_and_Unspecified_Diagnosis-220725_Transcript.pdf**
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 1
Other Specified and Unspecified Diagnosis
Program Transcript
NARRATOR: You gather information from a client to diagnose during an intake. What
happens if the client does not meet the required symptoms to make the diagnosis? It
might have feeling tentative about what to diagnose. You may have heard or seen
tentative, provisional, or rule-out diagnoses. Those terms may describe your
uncertainty, but do they have a place and a diagnosis?
The answer is a simple no for social workers. Some agencies utilize these terms after
they code a diagnosis. Although, for best practice, you are strongly advised to avoid
them. You'll see why soon. But first, let's focus on the best practice, using other
specified or unspecified.
In real-world settings, be prepared for clients who do not meet every required symptom
of a disorder. A client may arrive with depression, lethargic, and experiencing a loss of
pleasure or interest. They report a diminished ability to concentrate. These are some
criteria for major depressive disorder. But to diagnose a depressive episode, you need
five of the nine listed symptoms. And right now, you only have three. At this point, you
cannot legitimately diagnose major depressive disorder.
Still, your detective skills point you strongly in this direction. How do you diagnose? In
every category of the DSM-5-TR, there are two options called other specified and
unspecified disorders. Both mean the client does not meet the full criteria for a disorder.
First, let's explore other specified disorder, which means the client is suspected to be in
this category, but the full criteria are not met, despite showing some symptoms. You are
diagnosing this fact and documenting the reason for the full disorder is not met, in this
case, not meeting five out of the nine symptoms. You must record the name of the
category followed by the specific reasons. F32.89 is the code for other specified
depressive disorder followed by a comma, followed by the reason why they don't meet
the criteria.
You can also use unspecified disorder, also an option in every category. Here, you do
not need to say why certain criteria are not met, while still recording a diagnosis that is
acceptable. Note that the number code is different in each of these. These are
legitimate diagnoses, and they are covered by insurance.
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 2
Why should you not use tentative, provisional, or a rule-out diagnosis when you don't
have all the criteria, even if an agency would allow it? There is no code that
corresponds to the words tentative, provisional, or rule out. Using these as if they are
implied from codes, is essentially saying the client meets the criteria for a disorder.
Note the difference between the provisional code and the other specified code. One
code records a specific disorder that may not be present. It may be recorded on records
without the provisional noted, which could be confusing or ultimately inaccurate. When
the code is submitted to insurance companies, there is not a spot for the word
provisional, and sometimes just the code itself may appear on a form. So the insurance
accepts this as the client's diagnosis when they never fully met the criteria, except, as
we noted, we're not fully sure it's major depressive disorder yet.
The other specified code is in its own unique code that accounts for how the client
actually presents. Using other specified and unspecified diagnoses are the best ways to
still work within the parameters of proper diagnoses, but account for the reality of a
complex process. They allow you to be accurate while you continue evaluating the client
for the best treatment.
**## SOCW6090_W03_How_to_Write_Diagnosis_DSM5TR.pdf**
© 2022 Walden University, LLC 1
How to Write a Diagnosis According to the DSM-5-TR
Writing a Diagnosis
A diagnosis is written as a simple list in order of priority to the current treatment
needs. For example:
F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern
F41.1 Generalized anxiety disorder
Z60.3 Acculturation difficulty
Note: Each diagnosis needs a code that is written before the name of the diagnosis.
How to Code
A diagnostic code, even when using the DSM-5-TR, follows the ICD-10 code
structure. The code structure is between three (3) and seven (7) characters. The
figure below shows how each digit in the code is organized.
Alpha
(Not U) Numeric Characters 3–7 can be any combination
of alpha or numeric
1st
digit
2nd
digit
3rd
digit • 4th
digit
5th
digit
6th
digit
7th
digit
Category Etiology, anatomical site, severity Extension
For mental health conditions, codes always start with a letter F, followed by two to six
(2– 6) digits. A code is not valid unless it has been coded to the full number of
digits required.
A code with only the first three digits is used only if that condition is not further
subdivided within the DSM-5-TR. For example, for schizophrenia, there are no
additional characters in Spaces 4, 5, 6, and 7.
F20.9 Schizophrenia
In other cases, numbers must be added in the 4th, 5th, or 6th spaces to individualize
a condition. Spaces 4–6 provide greater detail of causes and severity. For example,
here are two codes for mania:
F31.11 Bipolar I disorder, current episode manic, mild
2
F31.13 Bipolar I disorder, current episode manic, severe
Many disorders have more than one ICD code when there are common and clearly
identified subtypes to the illness. The diagnostic criteria box always tells you if a
code must be subdivided.
If you do not see a code at the top of the diagnostic criteria box, look for the correct
codes at the bottom of the box. Often the box prompts for further individualization by
saying “Specify if” or “Specify whether.” You may also be asked to set a severity
level.
The wording “specify whether” tells you that the subtypes that follow are mutually
exclusive.
For example, here are two subtypes for schizoaffective disorder:
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
Always check for coding notes for further directions. For example, in addition to
our subtypes for schizoaffective disorder, if catatonia is present, an additional code is
found in the coding note.
Coding note: Include the name of the medical condition in the name of the
mental disorder (e.g., F06.1 catatonic disorder due to hepatic encephalopathy).
The other medical condition should be coded and listed separately immediately
before the catatonic disorder due to the medical condition (e.g., K72.90 hepatic
encephalopathy; F06.1 catatonic disorder due to hepatic encephalopathy).
Now the diagnosis looks like this:
F25.0 Schizoaffective disorder, bipolar type
F06.1 Catatonia (associated with another mental disorder)
Some disorders, such as the substance/medication-induced disorders, have more
complex codes for their subtypes. When this happens, there is always a table and a
coding note found at the bottom of the diagnostic criteria box.
How to List Multiple Codes
Formal DSM-5-TR diagnosis combines into one list all relevant mental disorders,
including personality disorders. The DSM-5-TR also expands the psychosocial
stressors that a patient might be experiencing. These are called “Other conditions
that may be a focus of clinical attention” and most begin with the letter “Z.”
© 2022 Walden University, LLC
© 2022 Walden University, LLC 3
These conditions, which are critical to psychosocial treatment, are found near the
end of the manual.
In a diagnostic list, always place the principal diagnosis first (the reason for the
visit, if in an outpatient setting). Other mental health comorbid diagnoses follow in
order of priority to the treatment or focus of attention.
RULE A: In this diagnostic list, a mental disorder was the reason for the visit.
Other psychosocial factors relevant to the service are listed after mental health
conditions
F40.00 Agoraphobia
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
The order of priority above is (a) principal mental health diagnosis, (b)
psychosocial needs.
RULE B: If the client above has a clinical diagnosis of a mental health problem
as the principal diagnosis (all F codes), with the presence of a second, the
diagnosis looks like this:
F40.00 Agoraphobia
F50.01 Anorexia nervosa, restricting subtype
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
© 2022 Walden University, LLC 4
References
American Psychiatric Association. (2022a). Diagnostic and statistical manual of mental
disorders (DSM-5-TR) (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787
American Psychiatric Association. (2022b). DSM-5-TR online assessment measures.
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-
resources/assessment-measures
Centers for Disease Control and Prevention. (2017). ICD-10-CM official guidelines for
coding and reporting: FY 2017 (October 1, 2016–September 30, 2017).
https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
Centers for Disease Control and Prevention. (2022). International classification of
diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from
https://www.cdc.gov/nchs/icd/icd-10-cm.htm
CMS.gov. (2021). Provider resources.
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources
World Health Organization. (2022). ICD-11: International classification of diseases for
mortality and morbidity statistics: Reference guide (11th ed.).
https://icdcdn.who.int/icd11referenceguide/en/html/index.html
**DiagnosisofNeurodevelopmentaland.docx**
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**## SOCW6090_W03_RedFlags_KeyWords.pdf**
© 2022 Walden University, LLC
Red Flags and Their Key Words
When evaluating clients, be aware of what is being said, what is unspoken, and any
nonverbal messages the client is sending. There are certain words mentioned by a
client that may lead you to evaluate for certain disorders first, and then followed by
evaluating the differential diagnosis. Below are some words—i.e., “red flags”—to help
you evaluate for certain disorders. You still need to be open to other possibilities, but
this will give you a place to start.
Schizophrenia and Other Psychotic
Disorders
I hear people talking to me.
They are telling me . . .
They are after me.
Client’s speech does not make sense.
Bipolar I’m on top of the world.
I bought all this stuff.
I do not need much sleep.
Client’s speech is very fast
Depressive Disorders I am depressed.
I do not want to go out anymore.
I do not want to wake up.
I cannot sleep. I am so tired.
I gained weight recently.
I lost weight recently.
I cannot concentrate.
Anxiety Disorders I worry about everything.
I am up at night thinking.
I have anxiety attacks.
I panicked out of nowhere.
Obsessive compulsive disorders I worry about the dirt in my house.
My thoughts go round and round.
I do repetitive behaviors.
I have repetitive thoughts.
Trauma and Stressor-Related Disorders I am easily startled.
I have nightmares.
I do not want to talk about the situation.
I no longer go to those places.
I avoid those people.
Dissociative Disorders I have gaps in my memory.
“We”. . .
“They”. . .
**## SOCW6090_W03_Diagnosis_Assignment_Tips.pdf**
© 2022 Walden University, LLC
Tips and Guidelines for Practice Diagnosis in This Course
Consider printing this tip sheet. Keep it next to you as you work through each practice
diagnosis.
Remember: After the intake assessment, you must make a diagnosis. In this course,
the details you would normally observe and assess are found in the written case study
that you read. With the case studies, apply the criteria in an applicable assessment
measure to gauge symptoms and severity based on details in a case study.
Also, utilize the resources in the course, such as the American Psychiatric Association’s
Online Assessment Measures (see the online classroom for the most up-to-date link).
For these, you would use an applicable questionnaire to guide an interview and follow
the guidance within each assessment measure.
When diagnosing, place the diagnosis (i.e., the diagnostic code—F followed by the
number and disorder name) before your summary. It must look like this:
F33.3 Major depressive disorder, recurrent episode, with psychotic features
F42 Obsessive-compulsive disorder, with poor insight
F10.20 Alcohol use disorder, in sustained remission
Z56.9 Other problem related to employment
Z60.9 Unspecified problem related to social environment
Other Tips
1. ICD 10 codes MUST be used (e.g., F60.90).
2. Z codes must be added. These are psychosocial and environmental stressors
impacting the case over the last 12 months.
3. Cases may include any diagnoses previously covered in earlier weeks.
4. Look for all possible diagnoses for the case, not just those related to the readings
for the week.
o No cases will include diagnoses that have not been covered in earlier
weeks.
5. Differential diagnosis means the case has similar symptoms—it does not mean
compare any case in the DSM-5-TR.
6. When explaining your decision in the summary portion please include the criteria
in the case that refer to the symptoms you are noting.
7. Read the directions in the course.
**## casestudy.docx**
**Week 3: Case assignment**
**CASE of OMARI**
**INTAKE DATE: May xxxx**
**IDENTIFYING/DEMOGRAPHIC DATA:** Omari is a 10-year-old male in the third grade. He lives in Houston, Texas with his parents. He is the only child of parents who have completed post-graduate education. The family is from St. Lucia and relocated to the United States when Omari was 6 months old for job opportunities. Omari is an intelligent young boy who presents with significant potential to excel academically.
**CHIEF COMPLAINT/PRESENTING PROBLEM:** Omari was referred for an evaluation because
his parents and teacher indicate that Omari is restless and often requires reminders to help him stay on task. Omari has difficulty focusing on and sitting still in class. He is described as "constantly running around" and presented with difficulties listening and following instructions. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior.
**HISTORY OF PRESENT ILLNESS:** Omari enjoys spending time with his friends. Most recently Omari was found in a neighbor’s house that he broke into.
The friend group recently found fires in the woods and neighbors called the police. While Omari interacts well with peers about his own age, his parents believe he is easily led and influenced by others. Omari does get upset when he does not receive what he wants and acts out, forcing others to give things to him. He physically and verbally fights with his peers when this happens but then he gets back hanging around with his friends.
Omari can 'hyper focus' on some activities of interest, however he often has difficulty sustaining his attention at school. Omari has been known to blurt out answers and interrupts other students in the classroom. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. He is easily frustrated and emotionally impulsive and has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in first and second grades.
**PAST PSYCHIATRIC HISTORY:** This is the first evaluation for Omari.
**SUBSTANCE USE HISTORY:** Omari denies any substance use.
**PAST MEDICAL HISTORY:** Omari has had normal childhood illnesses. He has had all vaccinations.
**FAMILY MEDICAL AND PSYCHIATRIC HISTORY:** Omari’s parents deny any psychiatric family history. There were noted medical histories from the family. The family living in St. Lucia has a different perspective of medical and psychiatric illness than those living in the United States. They believe in more natural intervention for illnesses.
**MENTAL STATUS EXAM:** Omari is dressed appropriately and looks like his stated age. At times during the interview, he would become frustrated and want to leave. Omari was oriented to time, place and person. Omari was able to repeat the words given to him. He denied suicide and homicide ideation.
**## Other_Specified_and_Unspecified_Diagnosis-220725_Transcript.pdf**
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 1
Other Specified and Unspecified Diagnosis
Program Transcript
NARRATOR: You gather information from a client to diagnose during an intake. What
happens if the client does not meet the required symptoms to make the diagnosis? It
might have feeling tentative about what to diagnose. You may have heard or seen
tentative, provisional, or rule-out diagnoses. Those terms may describe your
uncertainty, but do they have a place and a diagnosis?
The answer is a simple no for social workers. Some agencies utilize these terms after
they code a diagnosis. Although, for best practice, you are strongly advised to avoid
them. You'll see why soon. But first, let's focus on the best practice, using other
specified or unspecified.
In real-world settings, be prepared for clients who do not meet every required symptom
of a disorder. A client may arrive with depression, lethargic, and experiencing a loss of
pleasure or interest. They report a diminished ability to concentrate. These are some
criteria for major depressive disorder. But to diagnose a depressive episode, you need
five of the nine listed symptoms. And right now, you only have three. At this point, you
cannot legitimately diagnose major depressive disorder.
Still, your detective skills point you strongly in this direction. How do you diagnose? In
every category of the DSM-5-TR, there are two options called other specified and
unspecified disorders. Both mean the client does not meet the full criteria for a disorder.
First, let's explore other specified disorder, which means the client is suspected to be in
this category, but the full criteria are not met, despite showing some symptoms. You are
diagnosing this fact and documenting the reason for the full disorder is not met, in this
case, not meeting five out of the nine symptoms. You must record the name of the
category followed by the specific reasons. F32.89 is the code for other specified
depressive disorder followed by a comma, followed by the reason why they don't meet
the criteria.
You can also use unspecified disorder, also an option in every category. Here, you do
not need to say why certain criteria are not met, while still recording a diagnosis that is
acceptable. Note that the number code is different in each of these. These are
legitimate diagnoses, and they are covered by insurance.
Other Specified and Unspecified Diagnosis
© 2022 Walden University, LLC 2
Why should you not use tentative, provisional, or a rule-out diagnosis when you don't
have all the criteria, even if an agency would allow it? There is no code that
corresponds to the words tentative, provisional, or rule out. Using these as if they are
implied from codes, is essentially saying the client meets the criteria for a disorder.
Note the difference between the provisional code and the other specified code. One
code records a specific disorder that may not be present. It may be recorded on records
without the provisional noted, which could be confusing or ultimately inaccurate. When
the code is submitted to insurance companies, there is not a spot for the word
provisional, and sometimes just the code itself may appear on a form. So the insurance
accepts this as the client's diagnosis when they never fully met the criteria, except, as
we noted, we're not fully sure it's major depressive disorder yet.
The other specified code is in its own unique code that accounts for how the client
actually presents. Using other specified and unspecified diagnoses are the best ways to
still work within the parameters of proper diagnoses, but account for the reality of a
complex process. They allow you to be accurate while you continue evaluating the client
for the best treatment.
**## SOCW6090_W03_How_to_Write_Diagnosis_DSM5TR.pdf**
© 2022 Walden University, LLC 1
How to Write a Diagnosis According to the DSM-5-TR
Writing a Diagnosis
A diagnosis is written as a simple list in order of priority to the current treatment
needs. For example:
F33.1 Major depressive disorder, moderate, recurrent, with seasonal pattern
F41.1 Generalized anxiety disorder
Z60.3 Acculturation difficulty
Note: Each diagnosis needs a code that is written before the name of the diagnosis.
How to Code
A diagnostic code, even when using the DSM-5-TR, follows the ICD-10 code
structure. The code structure is between three (3) and seven (7) characters. The
figure below shows how each digit in the code is organized.
Alpha
(Not U) Numeric Characters 3–7 can be any combination
of alpha or numeric
1st
digit
2nd
digit
3rd
digit • 4th
digit
5th
digit
6th
digit
7th
digit
Category Etiology, anatomical site, severity Extension
For mental health conditions, codes always start with a letter F, followed by two to six
(2– 6) digits. A code is not valid unless it has been coded to the full number of
digits required.
A code with only the first three digits is used only if that condition is not further
subdivided within the DSM-5-TR. For example, for schizophrenia, there are no
additional characters in Spaces 4, 5, 6, and 7.
F20.9 Schizophrenia
In other cases, numbers must be added in the 4th, 5th, or 6th spaces to individualize
a condition. Spaces 4–6 provide greater detail of causes and severity. For example,
here are two codes for mania:
F31.11 Bipolar I disorder, current episode manic, mild
2
F31.13 Bipolar I disorder, current episode manic, severe
Many disorders have more than one ICD code when there are common and clearly
identified subtypes to the illness. The diagnostic criteria box always tells you if a
code must be subdivided.
If you do not see a code at the top of the diagnostic criteria box, look for the correct
codes at the bottom of the box. Often the box prompts for further individualization by
saying “Specify if” or “Specify whether.” You may also be asked to set a severity
level.
The wording “specify whether” tells you that the subtypes that follow are mutually
exclusive.
For example, here are two subtypes for schizoaffective disorder:
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
Always check for coding notes for further directions. For example, in addition to
our subtypes for schizoaffective disorder, if catatonia is present, an additional code is
found in the coding note.
Coding note: Include the name of the medical condition in the name of the
mental disorder (e.g., F06.1 catatonic disorder due to hepatic encephalopathy).
The other medical condition should be coded and listed separately immediately
before the catatonic disorder due to the medical condition (e.g., K72.90 hepatic
encephalopathy; F06.1 catatonic disorder due to hepatic encephalopathy).
Now the diagnosis looks like this:
F25.0 Schizoaffective disorder, bipolar type
F06.1 Catatonia (associated with another mental disorder)
Some disorders, such as the substance/medication-induced disorders, have more
complex codes for their subtypes. When this happens, there is always a table and a
coding note found at the bottom of the diagnostic criteria box.
How to List Multiple Codes
Formal DSM-5-TR diagnosis combines into one list all relevant mental disorders,
including personality disorders. The DSM-5-TR also expands the psychosocial
stressors that a patient might be experiencing. These are called “Other conditions
that may be a focus of clinical attention” and most begin with the letter “Z.”
© 2022 Walden University, LLC
© 2022 Walden University, LLC 3
These conditions, which are critical to psychosocial treatment, are found near the
end of the manual.
In a diagnostic list, always place the principal diagnosis first (the reason for the
visit, if in an outpatient setting). Other mental health comorbid diagnoses follow in
order of priority to the treatment or focus of attention.
RULE A: In this diagnostic list, a mental disorder was the reason for the visit.
Other psychosocial factors relevant to the service are listed after mental health
conditions
F40.00 Agoraphobia
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
The order of priority above is (a) principal mental health diagnosis, (b)
psychosocial needs.
RULE B: If the client above has a clinical diagnosis of a mental health problem
as the principal diagnosis (all F codes), with the presence of a second, the
diagnosis looks like this:
F40.00 Agoraphobia
F50.01 Anorexia nervosa, restricting subtype
Z60.3 Acculturation difficulty
Z72.0 Tobacco use disorder, mild (nicotine use)
© 2022 Walden University, LLC 4
References
American Psychiatric Association. (2022a). Diagnostic and statistical manual of mental
disorders (DSM-5-TR) (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787
American Psychiatric Association. (2022b). DSM-5-TR online assessment measures.
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-
resources/assessment-measures
Centers for Disease Control and Prevention. (2017). ICD-10-CM official guidelines for
coding and reporting: FY 2017 (October 1, 2016–September 30, 2017).
https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf
Centers for Disease Control and Prevention. (2022). International classification of
diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from
https://www.cdc.gov/nchs/icd/icd-10-cm.htm
CMS.gov. (2021). Provider resources.
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources
World Health Organization. (2022). ICD-11: International classification of diseases for
mortality and morbidity statistics: Reference guide (11th ed.).
https://icdcdn.who.int/icd11referenceguide/en/html/index.html
**DiagnosisofNeurodevelopmentaland.docx**
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