44 Chapter 2 include all the activities aimed at clarifying the complaints, the diagnosis and the needs for care (before any therapy). Examples of these activities are for example the intake appointment with the patient for a first conversation, case history and psychological assessments; obtaining information from other professionals and the family; or physical examinations and additional laboratory/imaging research. The diagnosis is an essential part of a treatment record and it is determined based on the multi-axial classification Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). While each one of the five axis in DSM-IV gives different type of information about the diagnosis, in this paper we focus on information gathered under axis one and two – which allows us to characterize the type of disorder –, and under axis five, which consists of evaluating the Global Assessment of Functioning (GAF) at the opening and closing of the treatment record. Treatment records might include one or more diagnoses in axis I or II. For patients that have multiple concurrent disorders the main practitioner should select as the primary diagnosis the disorder that corresponds to the major source of concern should. Rated in axis 5, the GAF score is a therapistrated measure summarizing the mental health professional’s view of the patient´s disease severity by rating psychological, social and occupational functioning [2]. It is used to track and communicate the course of mental disorders over time, and to monitor response to treatment [3].The rating is based on information collected by the professional, from sources such as the patient herself, medical records and other health personnel, among others [4]. The GAF consists of a 100-point scale divided into 10-point interval categories (between 91-100 for superior functioning and 1-10 for persistent danger of severely hurting self or others – Table A3), each interval corresponding to anchor points (verbal instructions) and examples that describe symptoms and functioning relevant for the rating. Additional scoring within each 10-point interval provides the professional with the possibility of distinguishing severity further, although there are no specific instructions for this additional scoring [4]. In the therapy phase the patient can receive several types of treatments provided by different mental health professionals, who all register the time spent in the treatment record. The most common therapeutic activities fall into the categories of communication therapy (e.g psychotherapy of several types, psychoeducation, training) or pharmacotherapy (activities related to the use of medicines); less common categories are physical therapy (with techniques mostly aimed at brain stimulus through electricity, magnetic waves, among others), non-verbal therapy (creative or psychomotor activities), physiotherapy or occupational therapy. For all the activities above mental health professionals record the treatment minutes they spend directly with the patient, but also indirect time spent preparing and reporting the activities. Other patient related tasks such as travelling to provide care at the patient´s home are also recorded as treatment time. In addition to the treatment time spent in the activities above, treatment records include information about inpatient days (each 24 hours) and day care (each hour). These days/
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