SOP_NUMBER: 508.09-att-4
TITLE: Mental Health Diagnosis List
REFERENCE_CODE: VG20-0001
DIVISION: Mental Health Administration/Staff/Certification
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-03-01
WORD_COUNT: 238
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/667081
URL: https://gps.press/sop-data/508.09-att-4/

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

ATTACHMENTS:
  1. Mental Health Cover Sheets and Mental Health Record Documentation
     URL: https://gps.press/sop-data/508.09-att-1/
  2. Group Treatment Case Notes
     URL: https://gps.press/sop-data/508.09-att-2/
  3. Records Inventory
     URL: https://gps.press/sop-data/508.09-att-3/
  4. Mental Health Diagnosis List
     URL: https://gps.press/sop-data/508.09-att-4/
  5. Group Attendance Roster
     URL: https://gps.press/sop-data/508.09-att-5/

========================================================================
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: [  ] <6 months [  ] 6-12 months [  ] >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.