How to Write a DSM-IV Differential Diagnosis
A differential diagnosis is included in mental status exams during an initial assessment, using the Diagnostic and Statistical Manual (DSM) of mental disorders. A differential diagnosis refers to the determination between two or more similar diseases. In psychology, many disorders share common symptoms, such as anxiety or depression, and it can be difficult to diagnose some patients. When assessing your patient, you are usually required to provide a diagnosis for most insurance companies. It is important to note the distinctions between different disorders to help support your diagnosis.
Speak to your supervisor about the exact requirements when documenting your assessment. Different employers have different specific guidelines for documentation. Also, insurance companies have different requirements about diagnosis.
Include your diagnosis near the end of your mental status exam and assessment. Gather information about your patient’s history, symptoms, relationship and cognitive functioning before making a diagnosis.
List the differential diagnosis under the “Assessment and Plan” portion of your psychological exam. For psychological exams, you will use the multi-axial diagnosis found in the DSM-IV.
Provide any supporting evidence for your diagnosis over other differential diagnosis. For instance, if you diagnosed your patient with post traumatic stress disorder instead of generalized anxiety disorder, explain that the patient has flashbacks and nightmares related to a trauma.
Note the other disorders if you are not sure. In some cases, you can list a provisional diagnosis is you need more time to rule out other differential diagnosis. In these cases, you will list the diagnosis as “Rule Out” and then list the disorder that you need more time with the patient to determine if she has. Alternatively, if you are unsure about the differential diagnosis between two disorders, you can list both diagnosis with a “vs.” in between.