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Unlock The Diagnostic Assessment Course

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Introduction

Introduction: Welcome to Write it Right Course #1 - The Diagnostic Assessment

Learning Objectives

What This Course Covers

Where This Course Fits in the Series

Meet Marcus T.

TL;DR: What a Strong Diagnostic Assessment Looks Like

Coming up in Module 1

Downloads

🔗 Download Materials

Gold Standard Template

⭐️ Gold Standard Template - Diagnostic Assessment

Module 1: Intake Fundamentals and the Presenting Problem

Format Guide

Translating Client Language Into Clinical Headlines

The Fields of the Presenting Problem

The Golden Thread Starts Here

Marcus T.: Presenting Problem Practice

Example of a Strong Response

Coming Up: Biopsychosocial History

Module 2: Biopsychosocial History

FORMAT GUIDE

The Domains of a Biopsychosocial History

Mental Health History

Medical History

Substance Use

Genogram / Family of Origin

Developmental History

Current Family / Household

Trauma and Abuse History

Sexual Health

Vocational and Educational History

Military Service

Social History

Common Items Auditors Flag as Missing

The Clinical Relevance Test

Marcus T.: Biopsychosocial Practice

Coming Up: Mental Status Examination

Module 3: Mental Status Examination

The Audit Problem with the Generic MSE

The Domains of the MSE

How the MSE Connects to the Diagnosis

Marcus T.: MSE Practice

Coming Up: Risk Assessment

Module 4: Risk Assessment Documentation

The Core Risk Areas

What to Document for Suicidal Ideation

What to Document for Homicidal Ideation

Access to Lethal Means

The Additional Risk Factors

Risk Level Documentation

Validated Screeners

Safety Plans

Marcus T.: Risk Assessment Practice

Coming Up: Clinical Formulation

Module 5: Diagnostic Formulation Documentation

CPT Code at Intake: 90791

ICD-10 Codes: Why Specificity Matters

Severity Documentation: The Post-GAF Era

The Diagnosis

Differentials and Rule-Outs

The Behavioral Definition - The Key Component of the Golden Thread

The Diagnosis as the Golden Thread Anchor

Marcus T.: Diagnostic Formulation Practice

Coming Up: Prognosis, Medical Necessity, and Treatment Recommendations

Module 6: Strengths/Motivation/Barriers, Treatment Recommendations, Medical Necessity, Coordination of Care, Discharge, Prognosis, and the Golden Thread

Assessing for Strengths, Protective Factors and Motivation Levels

Assessing Potential Barriers to Treatment

Treatment Recommendations

Level of Care Assignment

Medical Necessity

Consideration of Psychopharmacotherapy

Coordination of Care and Community Resources

Discharge Planning at Intake

Prognosis

Marcus T.: Closing the Assessment Practice

You Have Completed the Core Curriculum

Coming Up: Telehealth Documentation

Module 7: Telehealth Documentation

The Core Telehealth Documentation Elements

What to Document at Intake vs. Every Session

Client Screen for Telehealth

Hybrid Care: In-Person and Telehealth

Telehealth for Minors

Marcus T.: Telehealth Practice

Coming Up: Complex and High-Acuity Scenarios

Bonus Module: Complex and High-Acuity Presentations

Overview

Multiple Diagnoses

Diagnostic Re-Evaluation

High-Risk Presentations

Adolescent Client DA

You Have Completed the Bonus Module

Closing: What You Learned

The Complete Diagnostic Assessment

📋 Feedback & Certificate

Badge Card

Write the audit-ready intake that opens the golden thread.

$ (USD)

Learn to write an audit-ready diagnostic assessment, section by section. This clinician-built course covers the presenting problem, biopsychosocial history, mental status exam, diagnosis, risk, and medical necessity, so your intake starts the golden thread and your documentation holds up.

Write it Right: Diagnostic Assessment | MC Clinical Documentation Course

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