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Clinical Pathways Resource Guide - CEIC

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Assessment Step 6:<br />

Determine Diagnosis: Principles<br />

1. Diagnosis is established more by history than by<br />

current symptoms.<br />

2. It is important to document prior diagnoses even if<br />

assessor is not licensed to make diagnoses.<br />

3. It is critical to tie mental health symptoms to<br />

specific periods of time, particularly times when<br />

active substance use was not present.<br />

4. Contextualize the assessment – where, when,<br />

with whom, how much, why??…..pros why?? ..pros and cons of<br />

use or med/tx compliance.<br />

CSAT 2005b<br />

78

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