headings explicitly included in the case report:

Assessment case report:

  1. Background

Reason for referral

Presenting problem

Relevant history

  1. Assessment

Preliminary assessment of symptoms and risk

Observations at interview

Assessment findings

  1. Analysis and Diagnosis

Formulation

Discussion of evidence-based theories

Diagnosis

  1. Recommendation
  2. Evaluation and Reflection

Evaluation of assessment process

Personal reflection on case report / or what this may look like

  1. Reference List

 

 

 

What I am trying to convey in the case report is:

 

  • sufficient diversity in client groups (i.e. different cultures )
  • presenting problems and intervention methods to reflect depth and breadth of required skills and knowledge
  • ethical and professional standards adhered to
  • referring clients to another health practitioner as necessary and managing potential role conflicts if this arises in the case report
  • contain clear and succinct written expression, without significant grammatical or spelling mistakes, using psychological terminology correctly
  • typed in prose format, using a professional standard of English language
  • no more than 2,750 words

 

Additional info for assessment report:

 

Report section heading Section subheading Content to be covered
A. Background

 

 Reason for referral

 

 ·       States the reasons for the referral, referral source and context of referral

·       States the number of sessions and dates of client contact
  Presenting problem

 

 ·       Identifies and describes the presenting problems and symptoms (mood, affect, cognition, behaviour) or organisational issues in sufficient detail to support the development of a formulation and diagnosis
  Relevant history

 

 ·       Includes relevant demographic details

·       Identifies relevant background information (client or organisational history)
B. Assessment

 

 Preliminary assessment of symptoms and risk ·       Includes information about the client’s current symptoms or issues at presentation

·       Risk factors are discussed or assessed and the report states how any identified risks were managed (if indicated)
  Observations at interview ·       Describes the client’s presentation at interview, behavioural observations, demeanour, current mental state
  Assessment findings ·       Describes assessment methods and any appropriate tests or instruments that have been selected for assessment (including the edition number and abbreviation where relevant)

·       Provides a brief rationale for the assessment method and tests used

·       Assessment methods and tests have been used and interpreted appropriately

·       Includes a summary of results and correctly integrates this information in the context of the overall assessment
C. Analysis and diagnosis Formulation

 

 ·       Identifies the predisposing vulnerabilities, precipitating (triggers), perpetuating (maintaining) and protective factors

·       Develops a case formulation integrating factors that account for the client’s presenting problem or target behaviour
  Discussion of evidence-based theories ·       Discusses relevant evidence-based theories and models, including how these inform diagnosis, formulation and intervention delivery
  Diagnosis

 

 ·       Provides formal diagnosis using standard diagnostic/classification systems relevant to the area of practice (organisational diagnoses must be based on psychological tools and processes)

·       Includes discussion about whether symptoms meet all diagnostic criteria using examples from the client’s presentation (or organisational diagnosis must be justified);
    if a diagnostic classification system is used, the intern must demonstrate their ability to establish whether each of the diagnostic criteria for each of these have been met; if a diagnostic classification system is not employed, the intern must indicate which system or framework is being used and justify how the diagnosis has been derived

·       Explores differential diagnoses providing reasons for inclusion or exclusion

·       If a formal diagnosis is not made, provide reasons for this decision.
D. Recommendation ·       Suggests possible courses of future evidence-based interventions and plans which are realistic given complexity of the issues, and the number of sessions available for treatment
E. Evaluation and reflection Evaluation of assessment process ·       Provides discussion on the validity and reliability of the assessment process and results
  Personal reflection on case report ·       Provides a personal reflection on the case, including lessons learnt and how practice might be modified in light of the experience
F. Reference list ·       Reference list provided in American Psychological Association (APA) format, including references to psychological tests and instruments used

 

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