OAR 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.