SOP 508.09-att-4: Mental Health Diagnosis List

Division:
Mental Health Administration/Staff/Certification
Effective Date:
March 1, 2022
Reference Code:
VG20-0001
Topic Area:
508 Policy-MH Administration/Staff/Certification
PowerDMS:
View on PowerDMS
Length:
238 words

Summary

This form is used to document and record mental health diagnoses for incarcerated individuals in GDC facilities. It captures principal and secondary diagnoses, relevant medical conditions including substance use and abuse history, treatment duration expectations, and required signatures from mental health care providers including psychiatrists, APRNs, and clinical psychologists. The completed form becomes part of the offender's mental health record and is retained for 10 years following discharge from mental health services.

Key Topics

  • mental health diagnosis
  • psychiatric evaluation
  • principal diagnosis
  • mental health record
  • level of care
  • psychiatrist
  • clinical psychologist
  • treatment duration
  • substance abuse history
  • trauma history
  • offender mental health
  • diagnostic documentation
  • mental health assessment

Full Text

SOP 508.09
Attachment 4

03/01/22

GEORGIA DEPARTMENT OF CORRECTIONS Facility: __________________________________________

Mental Health Diagnosis List Name: ___________________________________________

ID #:_____________________________________________

Date: ________________ Race: ________________________ Sex: ________________

DIAGNOSES:
Principal:_________________________________________________________________________________________

(Principal Diagnosis must also be entered on the Medical Problem List (Medical Record Section 1)
Other: ______________________________________________________________________________________________________

Other: ______________________________________________________________________________________________________

General medical conditions relevant to mental disorder(s) listed above:

- History of substance use or treatment [ ] Yes [ ] No

- History of physical/psychological/sexual abuse
relevant [ ] Yes [ ] No [ ] Clinically relevant [ ] Not clinically

- History of sexual offending. [ ] Yes [ ] No

- History of military combat experience [ ] Yes [ ] No [ ] Clinically relevant [ ] Not clinically relevant

CRITERIA FOR THE PRINCIPAL DIAGNOSIS:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Anticipated Duration of Treatment/Caseload Placement: [ ] 12 months

Level of Care when Diagnosis made: [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4 [ ] Level 5

SIGNATURES: Signing affirms your role in the provision of mental health care. Fill out a new Diagnostic List to Change/Add to Diagnosis.

|Primary Mental Health Care Provider|Col2|Col3|Col4|Col5|Clinical Psychologist|Col7|Col8|
|---|---|---|---|---|---|---|---|
|Signature|Print Last Name|Date|Level|Date|Signature|Print Last Name|Date|
|||||||||
|||||||||
|||||||||
||||||Psychiatrist/APRN|Psychiatrist/APRN|Psychiatrist/APRN|
||||||Signature|Print Last Name|Date|
|||||||||
|||||||||
|||||||||
|||||||||

# Keep On Top of Mental Health Record – Section 2

Form no. M20-01-05 Page 1 of 1

Retention Schedule: Completed forms shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or sentence,
the mental health file shall be placed within the offender’s health record and retained for 10 years.

Attachments (5)

  1. Mental Health Cover Sheets and Mental Health Record Documentation (1,301 words)
  2. Group Treatment Case Notes (222 words)
  3. Records Inventory (123 words)
  4. Mental Health Diagnosis List (238 words)
  5. Group Attendance Roster (90 words)
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