Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
CPT4 code
Name of the Procedure:
Brief Emotional/Behavioral Assessment
Common name(s): Emotional/Behavioral Screening, Psychological Inventory.
Technical/Medical terms: Depression Inventory, ADHD Scale.
Summary
A brief emotional/behavioral assessment is a standardized questionnaire used to evaluate emotional and behavioral issues such as depression or ADHD. The assessment is scored and documented to help healthcare providers understand a patient's mental health status.
Purpose
To identify and assess emotional or behavioral conditions like depression or ADHD.
The goal is to provide a baseline evaluation, inform diagnosis, guide treatment planning, and monitor progress over time.
Indications
- Persistent feelings of sadness or hopelessness.
- Difficulty focusing or staying on task.
- Hyperactivity or impulsive behavior.
- Significant changes in mood or behavior.
- Academic, social, or occupational difficulties.
Preparation
No specific preparation is typically required.
The patient may be encouraged to answer questions honestly and may be informed about the purpose of the assessment.
Procedure Description
- The patient is provided with a standardized questionnaire.
- The patient answers the questions based on their recent thoughts, feelings, and behavior.
- The healthcare provider scores the assessment according to predefined criteria.
- The results are documented in the patient's medical record and discussed with the patient.
Tools: Standardized questionnaires such as the Beck Depression Inventory or ADHD Rating Scale.
Duration
Approximately 15-30 minutes.
Setting
Outpatient clinic, primary care office, or school counselor’s office.
Personnel
Typically administered by psychologists, psychiatrists, primary care physicians, counselors, or trained nurses.
Risks and Complications
- Minimal risk involved.
- Possible discomfort or emotional distress when reflecting on personal issues.
- Rare risk of misinterpretation or inaccurate reporting.
Benefits
- Early identification of emotional or behavioral issues.
- Informed decision-making regarding further diagnostic evaluation or treatment.
- Enhanced treatment planning and monitoring of progress.
Recovery
No physical recovery needed.
Patients may be advised to follow up with their healthcare provider for further evaluation or to discuss the results.
Alternatives
- In-depth psychological evaluation.
- Behavioral consultation.
- Observation by parents, teachers, or caregivers.
Pros: More thorough understanding with detailed evaluation.
Cons: Time-consuming and may require specialized referrals.
Patient Experience
Patients might feel a range of emotions when answering the questionnaire, from relief to discomfort.
Efforts are made to ensure privacy and support throughout the process.