4 Simple Steps To A Great Clinical Assessment

You guys probably know that I’m always on the lookout for great niches and side hustles for mental health professionals.  So when Licensed Psychologist Maelisa Hall introduced herself  to me via email, she noted that she teaches “therapists how to create rock solid documentation so they can spend more time with their clients and less time on paperwork.”

I knew right then that I wanted to introduce you to her work for two reasons.  First, she has created a niche  that leverages her teaching skills and clinical knowledge into consulting with agencies and individual practitioners.  And, second, she is sharing a simple way to insure that your assessments are complete.  It’s my pleasure to introduce you to Dr. Maelisa Hall.

(If you are interested in writing a guest post, check out the guidelines here.)

____________________

A Guest Post by Maelisa Hall, Psy.D.

Using FIDO in Your Assessment

Have you ever spent time with a client and felt like you had a really good connection and idea about their needs, only to realize later on you have no idea how to fit those thoughts into a diagnosis or clear picture for treatment?

Maybe as you start to write up an assessment, the previously clear picture of your client is suddenly blurry on paper. I know this has happened to me.  I also know the reason why!  I forgot to make sure FIDO was in the assessment.

Regardless of how you feel about DSM-5, DSM-IV or diagnoses in general, every therapist needs the skills to document a clear picture of the client’s presentation and needs.

However, it’s easy to get side-tracked or distracted when talking with our clients. FIDO is an easy-to-remember acronym that covers all the bases when assessing client behaviors and needs and makes it very easy to write a clear picture of the client’s presentation. Here’s what FIDO stands for . . . .

Frequency

I’ll admit, this one can be hard for clients but it really helps to give the therapist a good picture and a great foundation for treatment planning.

Clients tend to say things like “I’m depressed all the time” or “He always does that” or “She never pays attention to me.”

This is a golden opportunity to use your skills and help clients define what they mean.

I like helping clients break up their day. For example, “How many times do you think she ignores you school . . . after school but before dinner . . . before bed?”

It helps the client (or parent) to really reflect on their statements and experience of the problem.

Intensity

We often hear vague descriptors or exaggerations such as “all the time” or “really bad.”

Intensity is also subjective as in “really bad” for one client might be “pretty good” for another.

The idea is to get a baseline and compare that to the current behaviors to determine the client’s subjective experience.

Having a clear picture of the intensity at intake is also a great way to measure progress during treatment.

Using a scale of 1-10 is an easily understandable way to do this i.e. “On a scale of 1-10 how anxious do you feel on a given day at work?”

And “Now, on a scale of 1-10 how anxious do you feel when you have to give a presentation at work?”

Duration

With duration we are trying to understand the length of the behaviors when they occur.

Does the client feel intense anger in short bursts (about 20 minutes), for about two hours, or feel angry all day when they are triggered?

Knowing these key differences will significantly impact your treatment modalities.

Ask for details and use timelines and calendars to assist the client in reflecting.

Onset

For an accurate picture of the client’s story it is important to know when the behaviors began.

This is usually the easiest area for the client to identify and often relates to the reason for seeking treatment at this time.

Perhaps the client started feeling depressed after the loss of a significant relationship or had been feeling depressed for some time and then a minor incident was the “straw that broke the camel’s back” and triggered thoughts of self-harm.

Documenting Your Assessment

Documenting a good assessment is like painting a picture of the client.

It is brief, descriptive and allows us to feel what the client is feeling in that moment.

It allows us to hone in on our focus for treatment and gives us an accurate picture of progress throughout treatment.

For clinicians who bill to insurance, it is the basis for which you will be paid and authorized to provide treatment (see a related post about providing diagnoses to insurance).

Assessment is truly the foundation by which we work as clinicians and a skill that requires perfecting over time.

Once you’ve mastered the art of FIDO, the act of writing out an assessment is a cinch!

With clear information your words will flow easily and start drawing that picture.

I recommend mastering FIDO first but also talk with your colleagues to see what tools they use for gathering information.

We are our best resource for each other.

Leave a comment below sharing the tools that you use for gathering information or what you find most helpful in considering the use of FIDO for your assessments.

__________________

 

About the Author: Dr. Maelisa Hall is a Licensed Psychologist and owner of QA Prep.  She loves helping therapists learn to make paperwork simple and easy.