Bipolar Disorder: Level-of-function evaluation

Documentation of monitoring the patient’s level-of-functioning in one of the following ways:
• Patient self-report documented by clinician in record OR
• Clinician documented review of patient-completed monitoring form/diary/tool OR
• Documentation in patient chart of the use of ONE level-of-functioning monitoring tool, examples are as follows:
o SOFAS: Social and Occupational Functioning Assessment Scale
o GARF: Global Assessment of Relationship Functioning
o GAF: Global Assessment of Functioning
o WASA: Workload and Social Adjustment Assessment
o PDS: Progressive Deterioration Scale (functional impairment; activities of daily living)
o PHQ-9: Question 2 (How difficult has it been for you….)
o SF 12 or SF 36
AND
Timeframe for numerator chart documentation
Documentation of assessment of level-of-functions at time of initial assessment and within 12 weeks of initiating treatment for bipolar disorder
(Note: While the acute phase of treatment varies per individual, it is during this period that the clinician attempts to closely monitor the patient progress and has the opportunity to interact with the patient to assess level-of-functioning. This acute phase has been defined by the Project’s content experts as having the possibility of lasting through the first 3 months of treatment/therapy; thus the 12 week period)