diagnosis determination note...jul 01, 2019 · bhs/sud, f308 page 1 of 1 july 2019 diagnosis...

BHS/SUD, F308 Page 1 of 1 July 2019 DIAGNOSIS DETERMINATION NOTE Client Name: Client ID: Substance Use Disorder Criteria Below: Identify the name of each substance and check off the DSM-5 criteria that have occurred in the past 12 months related to each substance. Substance #1: Substance #2: Substance #3: #1 #2 #3 1. Substance often taken in larger amounts or over a longer period than was intended ☐ ☐ ☐ 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use ☐ ☐ ☐ 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects ☐ ☐ ☐ 4. Craving, or a strong desire or urge to use the substance ☐ ☐ ☐ 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home ☐ ☐ ☐ 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance ☐ ☐ ☐ 7. Important social, occupational, or recreational activities are given up or reduced because of substance use ☐ ☐ ☐ 8. Recurrent substance use in situations in which it is physically hazardous ☐ ☐ ☐ 9. Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance ☐ ☐ ☐ 10. Tolerance, as defined by either of the following: a need for markedly increased amounts of the substance to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of the substance ☐ ☐ ☐ 11. Withdrawal, as manifested by either of the following: the characterizing withdrawal syndrome for the substance or substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms ☐ ☐ ☐ Total Number of Criteria Basis for Diagnosis Narrative (Document the basis or justification for the diagnosis using applicable DSM-5 criteria. Narrative should be individualized to capture client specifics for each criteria checked. Include all applicable DSM-5 specifiers, including if a client has only maintained sobriety in a Controlled Environment.) DSM-5 Diagnosis(es)/ICD-10 Code(s): ________________________________________________________________________________________________________________ LPHA or MD Printed Name and Credentials LPHA or MD Signature Date

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BHS/SUD, F308 Page 1 of 1 July 2019

DIAGNOSIS DETERMINATION NOTE Client Name: Client ID:

Substance Use Disorder Criteria Below: Identify the name of each substance and check off the DSM-5 criteria that have occurred in the past 12 months related to each substance.

Substance #1: Substance #2: Substance #3: #1 #2 #3

1. Substance often taken in larger amounts or over a longer period than was intended ☐ ☐ ☐ 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use ☐ ☐ ☐ 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects ☐ ☐ ☐ 4. Craving, or a strong desire or urge to use the substance ☐ ☐ ☐ 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home ☐ ☐ ☐ 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the

effects of the substance☐ ☐ ☐

7. Important social, occupational, or recreational activities are given up or reduced because of substance use ☐ ☐ ☐ 8. Recurrent substance use in situations in which it is physically hazardous ☐ ☐ ☐ 9. Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely

to have been caused or exacerbated by the substance☐ ☐ ☐

10. Tolerance, as defined by either of the following: a need for markedly increased amounts of the substance to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of the substance

☐ ☐ ☐

11. Withdrawal, as manifested by either of the following: the characterizing withdrawal syndrome for the substance or substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms

☐ ☐ ☐

Total Number of Criteria Basis for Diagnosis Narrative (Document the basis or justification for the diagnosis using applicable DSM-5 criteria. Narrative should be individualized to capture client specifics for each criteria checked. Include all applicable DSM-5 specifiers, including if a client has only maintained sobriety in a Controlled Environment.)

DSM-5 Diagnosis(es)/ICD-10 Code(s):

________________________________________________________________________________________________________________

LPHA or MD Printed Name and Credentials LPHA or MD Signature Date

Client Name: Client ID: Substance 1: Substance 2: 1Total Number of Criteria: 2Total Number of Criteria: 3Total Number of Criteria: LPHA or MD Printed Name and CredentialsRow1: DSM5 DiagnosisesICD10 Codes: DSM5 DiagnosisesICD10 Codes_2: Substance 3: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffClear Form: Basis for Diagnosis Narrative Document the basis or justification for the diagnosis using applicable DSM5 criteria Narrative should be individualized to capture client specifics for each criteria checked Include all applicable DSM5 specifiers including if a client has only maintained sobriety in a Controlled EnvironmentRow1: