2017 PASRR RFB Appendix H - clinical example - Jane Doe.doc

Preadmission Screening and Resident Review (PASRR) Level II Screens

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Care and Treatment Services

F-20853 (10/2016) Appendix H

PREADMISSION SCREEN AND RESIDENT REVIEW (PASRR) FOR CURRENT OR PROSPECTIVE NURSING HOME RESIDENTS—LEVEL II SCREEN FACESHEET

An asterisk (*) below denotes personally identifiable information that is necessary for tracking purposes by the Department of Health Services in its efforts to ensure compliance with federal and State regulations. This information is not to be used in any manner outside the scope of the contractual language and applicable laws or regulations.

Check one:

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Preadmission Screen

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Change of Status Resident Review (check the reason for referral below):

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Short-term exemption

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Not previously screened

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May not need nursing facility care

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May now need specialized services or specialized psychiatric rehabilitative services

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Per DHCAA policy

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May no longer need specialized services or specialized psychiatric rehabilitative services

Check one:

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Full Screen

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Partial Screen

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Abbreviated Screen

Check the appropriate box:

Screen for a person who may have an intellectual/developmental disability

Screen for a person who may have a serious mental illness

Name – Client *

Jane Doe County of Responsibility

Utopia

Date of Birth * xx/xx/1978 Gender

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Male

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Female Social Security Number *

111-11-1111

For Preadmission Screens Only—In what type of residence has the person lived (for at least three months) prior to the referral for a Level II Screen? (check one)

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Independent (apartment or house)

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Group Home (CBRF or Adult Family Home)

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With Relative

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ICF/IID

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Hospital

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Assisted Living (RCAC)

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Other—specify:

Was the person in a hospital during the time of the Level II screen?

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Yes

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No

Name – Current or Proposed (if known) Nursing Facility

Cross Wind Manor, Utopia, WI

Legal Status (check one) *

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Voluntary Admission

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Involuntary Admission

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Protective Placement Date of last Watt’s review

Name – Guardian or Health Care Agent, if applicable *

Address

Telephone Number – Home

Telephone Number – Work

Has the Durable Power of Attorney for Health Care document been activated?

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Yes

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No

PARTIAL LEVEL II SCREEN

Validation of an Intellectual/Developmental Disability Does the data about the person (see the Level II Screen, F-20852, page 1) meet the federal definition of a “developmental disability”?

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Yes—Continue with the screening process

No—No further Level II screening is needed.

Validation of a Serious Mental Illness Does the data about the person (see the Level II Screen, F-20378, page 1) meet the federal definition of a “serious mental illness”?

FORMCHECKBOX

Yes—Continue with the screening process

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No—No further Level II screening is needed.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s current medical record. If the person’s condition or diagnoses change so that he/she later may meet the federal definition of a developmental disability or a serious mental illness, the nursing home will need to submit an updated Level II screen to the appropriate PASRR contract agency.

ABBREVIATED LEVEL II SCREEN

Is an abbreviated Level II screen appropriate because the person qualifies for categorical determination that he/she does not need specialized services or specialized psychiatric rehabilitative services? (Check one)

Yes—there is support for the diagnosis of a severe medical condition AND the social history, progress notes, and other documentation indicate that the person’s level of functioning is so severely impaired by his/her medical condition that he/she could not be expected to actively participate or benefit from specialized services. This concludes the Level II process. Check the type of severe medical condition affecting the person:

Medical condition, including, but not limited to terminal illness (i.e., the individual has a medical prognosis that his/her life expectancy is six months or less if the illness runs its course), coma, ventilator dependence, functioning at a brain stem level, chronic obstructive pulmonary disease, Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, congestive heart failure, etc. Specify:

Severe cognitive impairments or deficits due to Alzheimer’s disease, dementia, or a related disorder.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s medical record.

No—support for the diagnosis of a severe medical condition was not found OR documentation was not found that indicates that the person’s level of functioning is so severely impaired by his/her medical condition that he/she could not be expected to actively participate or benefit from specialized services. If the documentation might exist, but it was not found or included by the PASRR contract agency, contact the appropriate PASRR contract agency to discuss the data that might exist and how to find or obtain the information. Otherwise, proceed to complete a full Level II screen.

APPROPRIATENESS OF PLACEMENT DETERMINATION

Please check one:

Yes, this person is appropriate for a placement in a nursing facility.

This is expected to be a short-term recuperative care stay.

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No, this person does not need placement in a nursing facility; however, he/she may choose to stay because he/she has resided in one or more nursing facilities for at least 30 consecutive months prior to this determination AND he/she was determined to need specialized services (see below).

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No, this person does not need placement in a nursing facility.

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It is recommended that this person be placed in a FORMCHECKBOX less

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more (check one) restrictive setting than a nursing facility, such as—specify:

NOTE: If a person has both an intellectual/developmental disability and a serious mental illness, the PASRR teams must coordinate their screens; the teams must agree on the placement determination.

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Check this box if the person has both an intellectual/developmental disability and a serious mental illness.

SPECIALIZED SERVICES DETERMINATION

Please check one:

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This person needs specialized services (i.e., inpatient psychiatric hospitalization) to address his/her mental health needs.

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This person needs specialized psychiatric rehabilitation services to address his/her mental health needs.

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This person needs specialized services to address his/her developmental disability needs.

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This person does not need specialized services or specialized psychiatric rehabilitative services.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s medical record.

PRINT/TYPE Name and Title - QIDP/QMHP Making the Determinations

FORMDROPDOWN

Date Level I Referral was Received

02/05/2017

02/10/2017

Skilled Nursing Care Level Required: Wisconsin administrative code requires that in order for a person who has an intellectual/developmental disability to be admitted to a nursing home, he/she must meet the criteria for a skilled nursing care level (SNF), as established by a Division of Quality Assurance (DQA) surveyor. In certain circumstances, DQA may waive the SNF care level requirement. A care level or waiver must be obtained prior to admission.

Department of Health Services

State of Wisconsin Division of Mental Health and Substance Abuse Services

F-20378 (Revised 10/2008)

LEVEL II Preadmission Screening/Annual Resident Review Assessment for

Persons with Mental Illness Applying for Admission or Residing in

Medicaid-Certified Nursing Homes Client’s Name:

Jane Doe

VALIDATION OF A SERIOUS MENTAL ILLNESS:

Does the data about the person meet the criteria for the federal definition of a “serious mental illness?”

( Yes (all questions below are answered “yes”). Continue with the screening process.

( No (at least one question below was answered “no”). No further Level II screening is needed.

Also, indicate the result of this determination on the first page of the Facesheet.

1. ( Yes ( No Does the person have a major mental disorder meeting the diagnostic requirements in DSM III-R of (circle the applicable diagnosis) schizophrenia; mood, paranoid, panic or other severe anxiety disorder; somataform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability. Note: Dementia, as described in DSM III-R, is not considered a major mental disorder, even though it is a mental disorder that leads to a chronic disability.

2. ( Yes ( No Has the person’s functioning been limited continuously or intermittently during the past 3 to 6 months in at least one of the following areas of major life activity (check the applicable areas):

Interpersonal functioning, including but not limited to: social isolation, altercations with others, difficulty interacting appropriately and communicating effectively with others;

Concentration, persistence, and pace resulting in problems, such as, difficulty completing common tasks found in a workplace, school, or home setting, difficulty in completing tasks on time, or frequent errors; and

Adaptation to change.

3. ( Yes ( No Has the person needed as a result of the mental disorder either psychiatric treatment that is more intensive than outpatient care (e.g., partial or inpatient hospitalization) at least two times during the past two years, supportive services to maintain functioning in the community, OR intervention by housing or law enforcement officials?

General Directions: The Level II Screen consists of the following five required assessment sections. The objective of each section is noted. All the assessments may be dictated. The Comprehensive Drug History and the Psychosocial Assessment may be written directly on the screen. Each assessment must be signed and dated (date of the completion of the assessment) by the professional who conducted the assessment.

I.

COMPREHENSIVE MEDICAL HISTORY AND PHYSICAL (PRIMARY CARE) EXAM DIRECTIONS: a) The objective is to determine the basic medical conditions which are present and to understand how they contribute to the need for nursing home placement; b) Include medical history, review of body systems, review of neurological system, diagnoses and treatment plan; c) If a physician’s assistant or nurse practitioner prepares the history and physical, it must be reviewed and signed by a physician.

A.

Components of the history and physical

1.

Major medical illnesses a.

Include all the basic diagnoses, problems, and symptoms and whether they are stable. If they are not stable, indicate how often they are present and how they affect the person’s daily life and ability to care for him/herself. Also, include any abnormal test results.

b.

Past significant history c.

May list past diagnoses for completeness if they occurred in the past, but are not currently under treatment, or would not be expected to become active, and therefore, would not have to be taken into consideration when treating any of the current diagnoses. For example, surgical history of hernia repair, appendectomy, traumatic amputation, history of Rheumatic fever, pneumonia at age 30, etc.

2.seq level3 \h \r0 Significant family history

3.

Review of all systems

4.

Physical exam

Vital signs

Exam

5.seq level3 \h \r0 Neurologic

Motor

Sensory

Gait d.

Deep tendon reflexes e.

Cranial nerves f.

Abnormal reflexes

6.seq level3 \h \r0 Treatment plan: For each current diagnosis under treatment, identify current treatment, e.g., medication, tests and any intervention or monitoring by nursing or therapy (physical, occupational, speech, etc.)

7.

Physician’s signature and date

B.seq level2 \h \r0 Meeting the medical history and physical exam requirement with existing records.

A previous hospital admission history and physical exam may be used if:

It is comprehensive and includes most of the points listed; and

It was done within the last three (3) months; and

It was accompanied by an update which was done within the last ten (10) days; and

It is accompanied by the previous records or information that are referenced.

Additional modifications can be made to the admission history and exam if they are made on the copy, initialed and dated by a physician.

Update

It must be done within the last ten (10) days;

It should cover any major episodes or hospitalizations that have occurred since the date of the hospital admission history and exam which is being used to satisfy this requirement; and

It should address the reason the person is being admitted to the nursing home and his/her physical condition at this time.

4.seq level3 \h \r0 Medical/Surgical consultations

If there is a medical condition, which is the reason for the nursing home placement and a consultant was involved with the care, then include a copy of the consultation and the key progress note.

Appendix H II.seq level1 \h \r0 seq level2 \h \r0 seq level3 \h \r0 COMPREHENSIVE DRUG HISTORY (CURRENT OR IMMEDIATE PAST MEDICATIONS USE BY THE PERSON) DIRECTIONS: a) The objective of the Drug History Assessment is to determine al current or immediate past medication that could mask or mimic mental illness symptoms; b) Include all medications prescribed during the last month and the use of PRNs and any use of over-the-counter medications; this section may be dictated or the form below may be used; and c) Drug data can be compiled by physicians, nurses or other staff trained to use the forms; however, the Drug Assessment must be completed by a psychiatrist.

A.

All medications

Frequency

Daniel Zimmerman

Individual Compiling Drug History Information

Date

B.

Assessment of drug history to be completed by psychiatrist performing the examination in Part IV. Are current medications masking symptoms or mimicking mental illness in this person?

See attached

Signature of Psychiatrist

III.seq level1 \h \r0 PSYCHOSOCIAL EVALUATION DIRECTIONS: a) The object is to determine the individual’s ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while in the community; b) The psychosocial evaluation requires the compilation of specific client information upon which the assessments in each category are based. The evaluation data should cover a minimum of two (2) years. If the person has been institutionalized the past two years, provide information regarding functioning level prior to institutionalization; c) The following forms are provided to organize the information that can be compiled by staff trained to go through the person’s records. The assessment should be completed and signed off by a QMHP and should include information pertinent to how the individual’s mental illness has effected his/her functioning level. This section may be dictated or the form below may be used.

Living Situation

Parents’ home birth - young adulthood

Grandfather’s house briefly - then decompensated and went to nursing home

Assessment

Jane was a poor historian who did not want to disclose much in the way of personal background. She has been in a few community placements, but decompensated and was not compliant with medications. Recently, some trial placements in the community have been attempted.

B.

Education

Highest Grade Completed

12th - High School Graduate

College degree - bachelor’s from Utopia Community College in Music/Education

Special Education Classes N/A

C.

Employment

competitive

Jane’s employment history is limited. She currently enjoys working in the laundry dept. of Cross Wind Manor. She indicated a desire to earn more money and relayed that she recently received a raise.

WORK EXPERIENCE - This category refers to a time-limited training process using structured work activities to increase understanding of work value and demands as well as to develop work behavior or work skill.

SHELTERED WORK - This category refers to work for subcompetitive wages or salary in a workshop conducted by a nonprofit organization which provides work under special conditions for persons with disabilities.

SUBSIDIZED - This category refers to work where the employer (or employee) receives monetary inducements from another source to hire (be hired) noncompetitive candidates for work.

COMPETITIVE - This category covers work for remuneration in business, industry, government or other organizations that exercise selective hiring practices based upon qualifications of available applicants. Positions are not time-limited and pay a market wage.

VOLUNTEER WORK - This category refers to work activity where time/service is contributed to an organization that typically accomplishes work by individuals by volunteering.

Appendix H

D.

Social History and Supports

Marital Status (Note Dates and Changes)

Single

2.

Children

None

N/A

Significant Others (e.g., spouse, parent, landlord, public defender, employer)

The records indicate Jane’s parents remain in contact with her and she is involved in a relationship with a male resident of the facility. It should be noted that this male is HIV positive. Staff and Jane’s psychiatrist have spoken with Jane re: sexual activity protection from HIV. Jane consents to sexual contact with this male and condoms are available.

E.seq level2 \h \r0 Substance Abuse/Illegal Drug Use N/A currently

Records indicate she experienced a drug overdose on two occasions approximately 10 years ago. Currently, she smokes cigarettes, but denies alcohol use. In 2013, she took a large dose of anti-psychotic meds and grandfather’s heart pills. Hospitalized at St. Mary’s Hospital, Utopia.

F.

Legal Status

Voluntary Admission

( Involuntary Commitment

Protective Placement & Guardian xx/xx/2013 - recommitted xx/xx/2014

The records indicate Human Services is continuing to plan for community placement for Jane; however an appropriate setting is not yet available.

G.

Current Financial Support

current

current

Medicaid pays for Jane’s stay at Cross Wind Manor. She indicates a desire to work more in order to have increased earnings. She manages her own funds - buys her own clothes at rummage sales in town.

Daniel Zimmerman, QMHP

Signature of Qualified Mental Health Professional (QMHP)

Date Completed

IV.seq level1 \h \r0 FUNCTIONAL ASSESSMENT: a) The objective is to determine the individual’s ability to engage in activities of daily living; b) include the level of support which would be needed to assist the individual to perform these activities while living in the community and where that level of support can be provided; c) data for this part of the assessment should be completed and signed off by any member of the team who meets the QMHP requirements.

Note: If the individual is dually diagnosed, completion of the Level II for persons with developmental disabilities meets the requirements for this section.

1.

Self-monitoring of health status (including monitoring and supervising one’s own health status and self-administering medication and scheduling medical treatment).

2.

Self-monitoring of nutritional status (eats balanced diet, appropriate snack foods, and fluids).

3.

Handling money (does not do or has skills but does not have opportunity to do).

4.

Dressing appropriately (on a daily basis; wears weather related clothing).

5.

Grooming (personal hygiene, combs hair, brushes teeth).

Daniel Zimmerman

Signature of QMHP completing the functional assessment

Date of the assessment

V.

COMPREHENSIVE PSYCHIATRIC AND MENTAL STATUS EVALUATION DIRECTIONS: a) The objective is to determine the individual’s psychiatric status and to determine whether or not the individual needs specialized services for those conditions; b) Include treatment history, recent and past psychiatric history, mental status exam, diagnoses and treatment recommendations; c) The data for this part of the assessment can be collected by staff trained to compile the past treatment information, but the assessment must be either reviewed and countersigned or completed by a board certified or board eligible psychiatrist.

Psychiatric and Mental Status Assessment

Psychiatric Treatment History

Inpatient Tx @ Hennepin Co. General

(suicidal, hallucinating)

2.

Recent Psychiatric History

Past Psychiatric History

4.

Mental Status Exam

General appearance

Psychomotor

Thought content: current abilities, overt behavior, suicidal/homicidal ideation, reality testing, presence and content of delusions and hallucinations

Thought form e.

Perceptions f.

Emotional state - Affect and mood g.

Orientation h.

Cognitive functioning and intellect i.

Judgment j.

Insight to his/her mental illness

5.seq level3 \h \r0 Summary of findings, including review of current treatment plan

6.

Diagnosis using DSM III-R (all five axes)

7.

Specialized services recommendations for each psychiatric diagnosis (include medication and other biological treatments, psychosocial and rehabilitation services, and other symptom management or psychotherapy)

Psychiatrist’s Signature

B.seq level2 \h \r0 Meeting the psychiatric/mental status requirement with existing records

A previous hospital admission history and psychiatric assessment may be used if:

It is comprehensive and includes most of the points listed; and

It was done within the last three (3) months; and

It is accompanied by an update that was done within the last ten (10) days; and

It is accompanied by the previous records or information that are referenced.

Additions and modifications may be made to the admission history and psychiatric assessment if they are made on the copy, initialed and dated.

Update

It must be done within the last ten (10) days; and

It should cover any mental illness or hospitalization that has occurred since the date of the hospital admission history and physical exam which is being used to satisfy this requirement.

Appendix H Jane Doe xx/xx/2015 History and Physical Examination: Major Medical Diagnoses: Jane Doe is a 38‑year‑old single woman who began having psychiatric problems about 15 years. For years now she has been treated as having bipolar disorder and has been on Lithium, Haldol, Thorazine and other psychotropic drugs without much benefit until Clozaril was added to her medications about a year ago. Since then she has gradually been weaned off of Lithium and is on Clozaril alone 150 mg. every morning and 300 mg. every hs.

She has had no significant medical history other than a drug overdose on two occasions about 10 years ago. Status post elective sterilization in 2003.

Medications: Clozaril as mentioned above. Otherwise Reguloid for constipation, one teaspoon b.i.d. Aspirin as needed for pain.

Family History: The patient reports that she has one sister that has been treated for depression. She also reports that her father has had a MI and hypertension and that her mother has had some kind of heart disease.

Review of All Systems: Patient denies chest pain, shortness of breath or other cardiopulmonary symptoms. No abdominal discomfort. No change in bowel habit except for the intermittent constipation that she experienced from atrophic medications. Review of her systems is negative. She does smoke but denies alcohol use.

Physical Examination: Patient is a rather tall attractive looking woman who appears to be her stated age of 38. She came into the examination with some ambivalence, but once here, participated fully in the physical exam and the mental status exam. Blood pressure 110/60, pulse 96, weight 165. She is in no acute distress. Appears to be active and in good health. Eyes: Equal and reactive. Extraocular movements are intact. Nose: Patent. Oropharynx without edema. Tongue protrudes midline. Gag reflux is intact. Neck is supple. There is no lymphadenopathy or thyroid palpable. Lungs are clear without rales, rhonchi or wheeze. Heart regular without murmur or gallop. Abdomen is soft, nontender without masses. There is no organomegaly. Extremities: Ankles: No edema. Neurologic: Motor strength is good throughout. Gait is normal. There are no sensory deficits. Cranial nerves are intact. The deep tendon reflexes are 2+. Normal Babinski’s.

Treatment Plan: Patient is not receiving treatment for any medical illnesses. She has been stabilized on Clozaril alone without Lithium. She needs no other medications. She is going on trial at a group home, Thompson House, on the 2lst of next month.

Psychiatric and Mental Status Examination:

Recent Psychiatric History: Jane was admitted as a patient at Cross Wind Manor in November 1992. Prior to her admission she had been on medications that included Lithium, Navane, Haldol and Thorazine. There was nothing to suggest that any of these drugs or combination of them had been helpful. There was a question of medication compliance when she was not in a structured setting. At the time of her admission here, she was put on Thorazine along with Lithium to establish baseline. The first few days after her admission she remained psychotic and was withdrawn, talked about hearing voices and also expressed anger towards the people around her. Along with this, she seemed depressed and was intermittently agitated. She had no understanding or insight into her mental condition. She took her medications but did not understand the benefit of them. She seemed to have a general disregard for rules, and tended to be aloof and guarded in her interactions with staff and other peers.

Appendix H In November 2014, Jane was recommitted for a year. She was showing some increase and disorganized behaviors. She was unable to follow through with simple expectations and did not seem to be stabilizing on Lithium and Thorazine. Without much response of these neuroleptic medications, she was considered a candidate for Clozaril. Clozaril was started about a year ago and had been increased up to her present level of 450 mg. every day. She improved within a few weeks; thinking clearer, she was less delusional, less paranoid and was able to concentrate better. She began taking responsibility for self, administering medications, showed some interest in discussing discharge plans, et cetera. As Jane improved, she was taken off of Lithium on a trial basis and suffered no relapse of symptoms from this. She began taking overnight passes and weekend passes with her family, continued to have some thought blocking and circumstantial associations but otherwise continued to improve. She began using downtown privileges well without disorganizing and continued to cooperate with her medications. For these reasons, primarily because she had an unsuccessful experience there before, she did not want to return to Thompson House after leaving here. However, this seems to be the only group home alternative that we have and she will go there on a trial basis on the 2lst of next month.

Past Psychiatric History: I do not have much history regarding the early onset of Jane’s illness. She is not a very good historian about this. She did finish high school and apparently college and was a substitute teacher for a time in 2000. The longest period that she ever lived on her own was for nine months. Otherwise, she lived either with her parents or grandparents. In 2010 she lived at the Wilson House, a halfway house. She then went to her grandfather’s home and after that in 2013 for a month at Thompson House. She did not cooperate with staff or with treatment plan.

She was treated by Dr. John Brown in Utopia for many years with bipolar disorder and had several admissions to St. Mary’s Hospital under his care. Hospital admissions, she was hearing voices, feeling suicidal and hearing voices telling her to kill her boyfriend. She was diagnosed with bipolar disorder, mixed with psychotic features. Treatment consisted primarily of Lithium and Haldol.

In September 2013, Dr. Smith, consulting psychiatrist, examined Jane for commitment hearing. He stated that the patient had a history of treatment noncompliance. She had no insight into her illness, and that she would continue to deteriorate if she was not in a structured environment. She was dangerous to herself and that her commitment could take place in the nursing home at Cross Wind Manor.

Mental Status Examination: Patient is a tall well-nourished healthy looking female who comes into the examining room with some ambivalence, accompanied by a nurse. She, at first, had poor eye contact, looked away from me all the time, but as the examination continued, she began to make better eye contact on a regular basis. Affect is somewhat blunted, but she does have affective range. Seemed pleasant during most of the examination. Expressed some concern about leaving Cross Wind Manor and going to the group home. She wondered how she would be able to work and to make friends. There is something of a clinging and dependent quality in her manner with me. She had some blocking in her speech, some difficulty completing sentences and in stating what was really bothering her. When I let her fumble for the right responses, she became obviously distressed and tearful. Hallucinations that she has mentioned in the past are less obvious to her now. She talked about voices that belonged to her sister that tended to be critical and she wished that she could validate these with her sister. When I pressed her on the issue of why she had not contacted her sister, she said that the two of them were not very close. She is alert, well oriented as person, place and time and has a good memory for past and recent events. She does not express any manic behavior, flight of ideas, tangentiality, et cetera. Certainly has no pressured speech. She does not seem to be overtly depressed at this time but mainly anxious about moving into the group home in two weeks. She denies suicidality. She has expressed to the staff some understanding of her illness and some willingness to accept responsibility for her treatment program. She tends to be rather dependent and may not do as well out of this structured environment as she is doing right now.

Appendix H Summary: This is a 38‑year‑old single woman who has a history of psychiatric problems that go back about 15 years. She went to college, apparently became a teacher, and then began to fall off in her functioning since then. In the time that she was working as a substitute teacher, apparently she had some kind of a psychotic break. After that she lived in group homes, halfway houses, lived with her parents and grandfather and ultimately began treatment in Utopia with Dr. John Brown for bipolar disorder. Neuroleptics and Lithium either separately or alone did not seem to be helpful to her. While here during the past year, she has been taking Clozaril with excellent results. Fewer psychotic symptoms, is functioning much better, is taking weekend passes home to her parents, is going into the community on her own and is now getting ready to have a trial at a group home, Thompson House.

Diagnosis:

Axis I:

Schizophrenia, chronic, undifferentiated.

Axis II:

Dependent personality disorder.

Axis III:

No diagnosis.

Axis IV:

Psychosocial stressors. The patient has been unable to establish herself independently except for one nine month period during her adult life; she has been treated for a chronic psychiatric illness over the past 15 years. She is somewhat alienated but overly dependent on her family. Has no friends.

Axis V:

Global assessment of functioning: 40 to 50. Patient has serious impairment in social, occupational and interpersonal relationships. Also continues to have some delusional problems which hinders her reality testing and communications with others.

Recommendations: The patient has had excellent results with Clozaril after years of medication failure with the traditional neuroleptic and with Lithium. Her psychotic symptoms have come under better management and control with Clozaril; the dependent personality is clearly showing through at this point and will complicate her efforts to live independently. Concur with the trial at the group home this month and would expect that she could make an adjustment there if she is compliant with her medications and with the other treatments and follow up counseling that she will need.

Dictated by Dr. Jones xx/xx/2015

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RFB No. S-0627 DCTS-17 Appendix H – Clinical Example/Test Case – Jane Doe