Appendix 6 Psychiatric Eval & Certificate of Need Templates.pdf

Community Behavioral Health Evaluations for Multiple Regions Solicitation # 26-MULTI-CS-BH-001

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Attachment X. PSYCHIATRIC EVALUATION REPORTS - Template

TEMPLATE

Psychiatric Evaluation Report

Updated 2017

CONFIDENTIAL REPORT OF PSYCHIATRIC EVALUATION

Date of Report:

Youth’s Name:

Date of Birth:

Home Address:

Parent/Guardian:

Case Manager:

1. Identifying Information & Reason for Referral

Must provide a physical description of the youth and state the youth’s gender, race/ethnic identity, and current residence.

Must specify the context, source, and reason for the referral.

Must include a statement that the limits of confidentiality have been explained to the youth and a statement that the youth understood what was explained.

2. Documents & Records Reviewed

Must list each of the background documents and records reviewed by the psychologist conducting the evaluation. If information was requested and not received, please note what was requested.

3. Persons Interviewed

Must list each person interviewed by name; stipulate whether the interview was face-to-face or by phone, and the person’s title or relations to the youth being evaluated, e.g., mother, father, sister, uncle, surrogate parent, community case manager, etc.

4. Legal History

Must summarize current and past legal problems, charges, convictions, detentions, probations, etc., especially sex offenses or pending charges.

5. Current Residence & Family History

Must include a family-of-origin structure, makeup of current household, stability of the home, frequency and emotional quality of youth’s relationships with parent(s) and other family members, current family problems and stressors (especially from the youth’s perspective), and history of family violence, substance abuse, or mental illness, as well as a summary of the family’s strengths.

6. Education Status and History

Must include the youth’s current school, grade and program (regular or special education) placement, recent and past academic performance, areas of academic difficulty and strength, attitude towards academics, perception of themselves as a learner, future educational or career goals, quality of their social relationships with peers and adults in school, and history of school adjustment difficulties and truancy/attendance problem.

7. Substance Abuse History greenj Cross-Out greenj Cross-Out greenj Cross-Out

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Must list each illicit street drug the youth has experimented with or currently uses (to include approximate date of last use) along with the frequency and amount used; provide the same information for alcohol use.

Must list any substance use disorder diagnoses the youth possesses and substance abuse counseling or treatment that has been received, If the youth has received substance abuse counseling, briefly describe the source, helpfulness, duration and type, e.g., outpatient or inpatient/residential, of substance abuse services received. Also document whether the youth feels s/he has a substance use problem and if they are receptive to receiving substance abuse counseling/treatment.

8. Mental Health History

Must describe the current and previous DSM-5 or ICD-10 disorders.

Must detail the youth’s and family-of-origin’s mental health history, to include diagnoses, hospitalizations, medications, psychotherapy, and treatment compliance. If the youth has received mental health counseling or treatment, treatment compliance and whether or not the youth found the counseling or treatment to be helpful?

Must detail if the youth has a history of suicidal ideation, plans, and attempts, describing the method used and the approximate date of each attempt.

9. DSM-5 Profile

Must specify diagnostic and clinical findings to include “Rule Outs” for disorder(s) that need further evaluation and “By History” qualifiers for active diagnoses made/treated by other health care providers. When full diagnostic criteria for a particular disorder have not been met, but the youth is “positive” for several clinically relevant (those having treatment or management implications) features of the disorder, list this disorder with the qualifier “Features”.

10. Trauma History

Must describe and provide approximate dates of emotionally and/or physically “traumatic” events the youth has been exposed to. Ascertain and document the emotional, cognitive, and behavioral ramifications of these traumatic experiences. Screen and document the presence of DSM-5 or ICD-

10 PTSD symptoms.

11. Medical Health History

Must specify if the youth is under the care of a physician for a medical illness or disorder, a description of the disorder(s) and the medications the youth is taking should be documented in this section.

12. Social History

Must summarize what is known or suspected about the youth with regards to the following: his/her personal strengths, ability to make and keep friends, perceptions of themselves as likeable or unlikeable, history of painful social rejection, ridicule, teasing, or being bullied, and the presence

(or absence) of people they can turn to for support and guidance in times of a crisis or when facing pressing personal problems.

13. Mental Status

Must document the youth’s orientation to person, place, year, month, and day-of-month. Describe youth’s mood, range (and appropriateness) of affect, thought pattern (for example - logical, loose association, tangential), presence or absence of active delusions, hallucinations, suicidal ideation/impulses/plans, judgment, insight, and ability to take/accept responsibility for his/her own actions. Also describe youth’s interpersonal comfort/lack-of-comfort with the interpersonal

Community Behavioral Health Evaluations for Multiple Regions Solicitation # 26-MULTI-CS-BH-001

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IFB for Department of Juvenile Services component of the assessment process and clinical impression of youth’s memory, receptive and expressive verbal skills.

14. Psychological Test Findings

Must specify all standardized full scale, subtest, and index scores, along with their percentile equivalents and “qualitative classification” relative to the standardization sample, must be presented for each test administered. Relative strengths and weaknesses (based on the statistical significance of score differences) in skills or abilities and “personality test” findings should be described with emphasis on their implication for the placement, education, management, or treatment needs of the youth evaluated. Include in this section youth’s measured or estimated intellectual ability

15. Risk of Danger to Self or Others

Must specify all information reviewed and obtained, should this youth be considered a “low”, “medium”, or “high” risk for doing harm to self or others? If judged to be either a “medium” or

“high risk”, describe what harmful behavior the youth is at risk for committing along with what has been learned about the youth via the evaluation process that supports the “medium” or

“high” risk classification.

16. Summary of Major Findings & Recommendations

Must provide a narrative summary of the salient evaluation findings with a list of recommendations for each problem area documented or discovered. This section of the report can be conceptualized as a “care-and-management- plan-of-action” (that will often include recommendations for family support, education, and intervention). In addition to itemizing “treatment” or counseling interventions needed. Recommendations may also include “in-home” or “out of home” residential placement based on which risk factors supported by the evaluation findings. The question of venue of treatment (whether out-patient or in-patient/residential) should minimally take into account the following factors: a) level of supervision/structure/environmental controls the youth needs, b) self and community safety concerns c) accessibility to treatment services needed and d) which type of placement, overall, provides the best opportunity for outcome success. If community placement is recommended, a “community safety plan”, i.e., measures needed to protect potential victims from the youth’s potential for re-offending, must be detailed in this section of the report. The specific name of a residential or community based program should not be stated in the placement recommendation.

If, in the opinion of the examiner, additional testing or referral to another professional - psychiatrist, neuropsychological testing, etc. - is warranted, these types of recommendations should be included in this section.

17. Psychotropic Medication History

Describe current and previous use of psychotropic medication including reasons for use and associated diagnosis, dosage, effectiveness and any known or documented allergies or untoward side effects.

18. Signature, Licensure, and Date

At end of report the examiner must provider his/her signature (with professional degree, e.g., Ph.D, MD, MSW, etc.) and the date the completed report was signed. In addition to a written signature and date, the examiner’s name (first & last), degree, and license type must be typewritten to ensure readability.

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Attachment AA. Certificate of Need – Psychiatric Evaluation Reports –

Maryland Department of Juvenile Services

Revised July 2020

Confidential Report of Psychiatric Evaluation

Name:

Date of Birth:

Date(s) of Evaluation:

Date of Report:

Home Address:

Parent/Guardian:

Case Manager:

Identifying Information & Reason for Referral & Presenting Problem

Include here or below the precipitating event(s), and reason that RTC is being considered.

Note: Must include a statement that the limits of confidentiality have been explained to the youth and a statement that the youth understood what was explained. Must also include the

“chief complaint” or reason(s) for the evaluation.

Documents & Records Reviewed

Note: This section should list each of the background documents and records reviewed by the psychiatrist conducting the evaluation.

Persons Interviewed

Note: List each person interviewed by name; stipulate whether the interview was face-to-face or by phone, and the person’s title or relationship to the youth being evaluated.

Legal History

Note: This section should summarize current and past legal problems, charges, convictions, detentions, probations, etc. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be descriptively accurate.)

Current Residence & Family History

Note: This section should include a family-of-origin structure, important caregivers, makeup of current household, stability of the home, frequency and emotional quality of youth’s relationships with parent(s), other family members and important caregivers, current family problems and stressors (especially from the youth’s perspective), and history of family violence, substance abuse, or mental illness. Under this sub-heading, the evaluator must state whether the

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IFB for Department of Juvenile Services youth’s current family/residential environment possesses the qualities or elements to provide a safe and stable place for the youth to live and receive adequate parental support, guidance, and supervision. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be descriptively accurate.)

Education Status and History

Note: This section should include the youth’s current school, grade and program (regular or special education) placement, recent and past academic performance, areas of academic difficulty and strength, attitude towards academics, perception of themselves as a learner, future educational or career goals, quality of their social relationships with peers and adults in school, and history of school adjustment difficulties. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be descriptively accurate.)

Mental Health History

Note: Current and previous disorders from the Diagnostic and Statistical Manual (DSM) should be described in this section. A history of previous mental health counseling and treatment(s) received should also be included in this section. Previous psychiatric hospitalizations, if any, must be itemized and describe (a) chief complaint, problem necessitating the hospitalization (b) name of the hospital (c) length of stay (d) discharge diagnosis (e) treatments received (f) outcome, i.e., impact on the youth’s mental health and behavioral functioning. This same information must be provided for each prior episode of non-hospital based or “community” mental health. If the youth has received mental health counseling or treatment, indicate if the youth find the counseling or treatment to be helpful. The youth’s history of suicidal ideation, plans, and attempts (describing the method used and the approximate date of each attempt) should also be included in this section. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be descriptively accurate.)

Treatment History

Include out-of-home treatment and non-treatment history; For youth previously placed in a DJS facility include the mental health treatment history; If youth was previously court ordered include the history of those ordered mental health services; were they completed, were the deemed effective at the time, and relapse (if any). Include attempts, and outcomes of prior increasingly intensive community based services.

Psychotropic Medication History

Note: Describe current and previous use of psychotropic medication including reasons for use and associated diagnosis, dosage, effectiveness and any known or documented allergies or untoward side effects.

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Psychological Test Findings (If a current psychological test data/report is available, has been reviewed, and is judged to contain information relevant to the current CON evaluation.)

Note: Reference & summarize psychological test findings with emphasis on their implication for the placement, education, management, or treatment needs of the youth evaluated.

Social History

Note: In this section summarize what is known or suspected about the youth with regards to the following: his/her ability to make and keep friends, perceptions of themselves as likeable or unlikeable, history of painful social rejection, ridicule, teasing, or being bullied, and the presence

(or absence) of people they can turn to for support and guidance in times of a crisis or when facing pressing personal problems. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be factually accurate.)

Trauma History

Note: Describe and provide approximate dates of “traumatic” events the youth has been exposed

to. Ascertain and document the emotional, cognitive, and behavioral ramifications of these traumatic experiences. Screen and document the presence of DSM 5 trauma and PTSD symptoms. (Findings contained in the psycho-social assessment report may be summarized or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be factually accurate.)

Medical History

Note: If the youth is under the care of a physician for a medical illness or disorder, a description of the disorder(s) and the medications the youth is taking should be documented in this section.

If youth had significant medical issues in the past describe the nature of this and any current effects.

Substance Abuse History (include how substance use is related but separate from the underlying mental health disorder that necessitates RTC level of care)

Note: List each illicit street drug the youth has experimented with or currently uses including use of prescription drugs for recreational purposes either prescribed for someone else or taking more than prescribed (to include approximate date of last use) along with the frequency and amount used; provide the same information for alcohol use. List any substance use disorders the youth possesses and substance abuse counseling or treatment that has been recommended or received. Also document whether the student feels s/he has a substance use problem and if they are receptive to receiving substance abuse counseling/treatment. If the youth has received previous substance abuse treatment, itemize each treatment episode and include (a) the name of the treatment provider (b) dates and length of treatment (c) whether the treatment program was successfully completed and (d) the length of sobriety the youth experienced while in treatment or post-treatment. (Findings contained in the psycho-social assessment report may be summarized

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IFB for Department of Juvenile Services or referenced here to the extent that the psychiatrist examiner concurs with these findings and/or judges the findings to be factually accurate.)

Mental Status (current psychiatric symptoms & behaviors)

Note: Document youth’s behavior during interviews. Document youth’s orientation to person, place, year, month, and day-of-month. Describe youth’s mood, range (and appropriateness) of affect, stream of thought (for example - logical, loose association, tangential, flight of ideas) and content of thought with presence or absence of active delusions, hallucinations, and suicidal or homicidal ideation/impulses/plans. Also describe youth’s interpersonal comfort/lack-of-comfort with the interpersonal component of the assessment process and clinical impression of youth’s memory, receptive and expressive verbal skills, judgment and insight.

Risk of Danger to Self or Others

Note: Based on the youth mental status, psychiatric symptoms, behaviors, history, intra-personal and interpersonal dynamics, should this youth be considered a “low”, “medium”, or “high” risk for doing harm to self or others? If judged to be either a “medium” or “high risk”, describe what harmful behavior the youth is at risk for committing along with what has been learned about the youth via the evaluation process that supports the “medium” or “high” risk classification.

(If the youth’s “risk status” for harm to self or others is material to the level of care recommended, this must be explicitly stated, along with other determining variables, as part of the justification for the level of care recommended in the section below.)

Summary of Major Findings & Recommendations (If recommending RTC include clear recommendations that the participant be placed in a RTC and the current treatment needs; note why services in the community are insufficient)

Note: Provide a narrative summary of the salient evaluation findings with a list of recommendations for each problem area documented or discovered including recommendations for psychotropic medication if applicable. This section of the report can be conceptualized as a

“care-and-management- plan-of-action” (that will often include recommendations for family support, education, and intervention). In addition to itemizing “treatment” or counseling interventions needed, it is also necessary to provide recommendations for “in-home” or “out of home” residential placement based on which placement options is supported by the evaluation findings. The question of placement should minimally take into account the following factors:

a) history of previous treatments provided and the youth’s response to these treatments c) the types of specific mental health treatments, setting, and expertise needed to effectively addressed the psychiatric and behavioral problems/deficits documented d) the least restrictive level of care needed to effectively and safely provide for the youth’s mental health and adaptive behavioral needs and e) an assessment of the youth’s ability to cooperate or comply with the rules or requirements of the level of care recommended. If RTC level of care is recommended, the evaluator must explain, with supporting facts or findings, why less restrictive/community based levels of care options would not be adequate, safe, or appropriate to meet the youth’s documented needs or problems. The specific name of a residential or community based program should not be stated in the placement recommendation.

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NOTE: if recommending RTC, note that youth needs to return to parent/guardian or another home-like environment

If, in the opinion of the examiner, additional testing or referral to another professional, e.g., psychologist, neurologist, educational specialist, speech / language therapist is warranted, this type of recommendation should be included in this section.

Diagnoses using DSM 5 (include all applicable eligible diagnoses)

Note: Provide diagnostic and clinical findings by following the format in DSM 5 or current

Diagnostic and Statistical Manual to include “Rule Outs” for disorder(s) that need further evaluation and “By History” qualifiers for active diagnoses made/treated by other health care providers. When full diagnostic criteria for a particular disorder have not been met, but the youth is “positive” for several clinically relevant (those having treatment or management implications) features of the disorder may be included with any qualifier.

When recommending RTC the diagnoses should meet the established requirements established by the Maryland Public Behavioral Health System or explain why the youth still meets the need for RTC level of care despite not meeting the diagnostic criteria.

Signature, Licensure, and Date

Note: At end of report the examiner must provider his/her signature (with professional degree, M.D., D.O.) and the date the completed report was signed. In addition to a written signature and date, the examiner’s name (first & last), degree, board certification, and license type must be typewritten to ensure readability.