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