Or. Admin. Code § 415-057-0060

Current through Register Vol. 63, No. 11, November 1, 2024

Section 415-057-0060 - Comprehensive Diagnostic Assessment

(1) Written Procedure: The program will develop and implement a written procedure for assessing each client's treatment needs that includes collection and assessing data obtained through interview, observation, testing, and review of previous treatment or other written records.

(2) Assessment: The diagnostic assessment will be documented in the permanent client record. The assessment will include:

(a) Clinical formulation of presenting problems; the six dimensions of the ASAM PPC 2-R; important biological, psychological and social factors; medical and trauma history; clinical events and course of substance use or mental illness including onset, duration and severity of presenting concerns; consumer or family expectations for recovery; justification for treatment services and prognosis; current medication regime; and data to support a DSM Five-axis Diagnosis;

(b) A Criminal Risk Factor Assessment and the individual Oregon Corrections Plan;

(c) Documentation of the client's self-identified cultural background, including level of acculturation, knowledge of own culture, primary language, spiritual or religious interests, and cultural attitude about Alcohol and Other Drugs use;

(d) The date of the assessment;

(e) The signature, signature date, and credentials of the program staff member completing the assessment; and

(f) If Alcohol and Other Drugs treatment is not appropriate or contraindicated, include a written statement justifying the determination.

Or. Admin. Code § 415-057-0060

ADS 2-2010, f. & cert. ef. 5-6-10

Stat. Auth.: ORS 413.042, 409.410 & 409.420

Stats. Implemented: ORS 430.240 - 430.640, 430.850 - 430.955, 813.010 - 813.052 & 813.200 - 813.270