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Provide the full DSM-5-TR diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention).
Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.
Identify 2–3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.
Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.
Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.
Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.
Identify client strengths, and explain how you would utilize strengths throughout treatment.
Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.
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