Lesson 2: Format Psych Evaluation Report

• identification - name, age, marital status, sex, occupation, language, race, nationality, religion, with whom the patient lives
• chief of complaint or reasons for referral - indicates exactly why the client came to the psychiatrist/psychologist/psychometrician or the reason why the client is in the institution preferably in the client's own words
• case background - talks about the case, onset, nature, probable reasons, and all
• history of present illness - chronological background and development of the symptoms or behavioral changes that cumulated in the patient's seeking assistance
• history of present illness - onset, effect, nature
• past psychiatric and medical history - emotional or mental disturbances, psychosomatic disorders, medical conditions, neurological disorders
• HPI - emphasize the present condition of the client
• PPMH - results of previous assessment
• avolition - decrease in motivation
• asociality - lack of interest in social interactions
• alogia - less speech
• anhedonia - inability to experience pleasure
• family history - nationality, persons at home, living conditions, source of income
• anamnesis - history of patient's life
• MSE

  * appearance

  * speech

  * mood and affect

  * thinking and perception

  * dreams and fantasies

  * sensorium

  * insight

  * judgment
• diagnosis - findings or conclusions about the illness are based on comprehensive assessment
• two ways of diagnosing

  1. dimensional approach - 4D's
  2. categorical approach - DSM
• differential diagnosis - other possible illness but was not able to meet the full criteria for diagnosis
• rule-in - why you consider certain disorders
• rule-out - why you did not diagnose with the disorder considered
• test evaluation procedure - test measurements used, results, interpretations, summary/synthesis
• predisposing - vulnerability
• predisposing - why; what personality/characteristics
• biological -hereditary or genetic cause
• predisposing biological - inherited gene from parents
• predisposing psychological - negative perception about self; poor coping style
• psychological - thought, mood, behavior
• social - interpersonal relationship, peer pressure, conformity, how we relate to other people
• precipitating - triggers; what happened prior to the onset
• perpetuating - why it continues?; factor that maintain the development of the disorder
• treatment plan - inpatient or outpatient treatment, frequency of sessions, probable duration of therapy. type of psychotherapy; symptoms or problems to be treated
• goals and interventions should always be align with the chief complaint
• secondary treatments

  * art therapy

  * music therapy