How to Write the First Clinical Interview Report

8 August 2016

Somewhere, sometime, as a mental health clinician we might conceivably do an evaluation and provide a complete course of treatment, or in our case, a complete document of first clinical interview of a patient. Regardless of where you work or who your patient may be, you will have to communicate your findings to someone. Working in hospitals, university counseling centers, community clinics, or private practices; you will commonly share your reports with psychiatrists, and any other medical personnel. And the reports that you prepared for your first clinical interviews will be one of those shared reports.

I. The Aims of Report Writing for the First Clinical Interview According to Cansever (1982), the aim of the psychological assessment report is to present the patient’s personality and to recommend the ways that will help the patient to solve his/her problems. However, in order to draw up a psychological assessment report, a clinical psychologist gathers information from three sources: interviews, observations, and psychological test results. For this semester and for this course; however, we only have a very first part of these three sources, namely first clinical interview.

How to Write the First Clinical Interview Report Essay Example

Nevertheless, in my opinion, the aim of the clinical psychologist may not be so different while he/she is writing a report of first clinical interview from the one while he/she is reporting the whole psychological assessment procedure. The aim is again to present the “patient” to others, and also to declare need of further information (from tests etc. ), to declare the treatment plan–if it is decided to begin the treatment, and if it is applicable–, and prognosis; all depending on the information that can be collected during a first session.

In addition, I think, simply to keep a record of the first session or to use it as a rich educational resource in academic settings can be some of the purposes while writing a first interview report. II. The Organization of the Written Report (Morrison, 2008) It is highly necessary to organize your findings before writing them. II. a. Identifying Data The identifying data provide the reader with a framework upon which to construct a mental image of the patient whose history you are reporting.

In the first lines of the report, you state the basic demographic data, including age, sex, marital status, education, and any other item that seems relevant. In any case, you should note that the patient either is new to your facility or has been seen there before. II. b. The Chief Complaint The chief complaint is the patient’s stated reason for coming to treatment. It is often written as a direct quote, but sometimes you may want to paraphrase or summarize it–especially when it is vague, long-winded, or multifaceted.

Moreover, a clinician may cite two chief complaints: one from the patient, and the other from a relative, friend, or other informant. This double reporting is especially useful for patients who are too confused or too uncooperative to respond appropriately when you request the information. In our reports written as a requirement of this course, of course, there will not be a chief complaint section since the individuals who we will be interviewing will not come to the session due to a complaint, rather they will be there to “help” us. II. c. Informants

Briefly state the names of those whom you have obtained your information from, and estimate the reliability of each. Besides the patient, mention relatives, friends, other health care workers, and old charts; that is to say, mention anything or anyone you have used to help visualize the picture of the patient. II. d. History of the Present “Illness” This section is the most important of the entire report. When you are writing up the history of the present “illness”, keep in mind several rules. 1. This should be a chronological history. Like all good stories, this one should have a beginning, some development, and an ending.

In most cases, it will begin with the onset of the first episode of illness. For example, it may be marked with an opening phrase like this: “Mr. Jackson was well until age 30, when he suffered the first of several episodes of depression. ” In this single economical sentence, note that the reader is alerted to (1) the principal area of clinical interest (mood disorder: depression), (2) the age of onset, (3) the fact that Mr. Jackson’s problem is not a new one, and (4) the patient’s good health during the decade of his adult life prior to the onset of his illness.

The additional information should proceed more or less chronologically, ending with the reasons that made your patient to enter the treatment at this time. 2. Support your best diagnosis/diagnostic impression/clinical conceptualization. This means that your writing should form a picture in which history, mental status, and possible diagnosis are mutually supportive portions of a consistent whole. 3. If the story is complicated, try to disentangle it. One way to accomplish this is to leave until later details that don’t support your best “diagnosis”. This less relevant information can be included later in the personal and social history.

You can also present distinct themes as separate paragraphs in your history of the present illness. After describing your patient’s depressive illness, which was actually the cause of his coming to the session, you might continue as follows: “In addition to his depression, Mr. Jackson has also had a problem with cross-dressing. This began at about the age of 6. ” 4. Edit your material so as not to make the readers learn far more than they will need to know. To boil down your material, you can summarize previous treatment in a line or two, categorize hospitalizations, and list symptoms of a typical episode.

This saves your reader from multiple repetitions of essentially identical information. As Platt and McMath (1979) have noted, “The present illness should be an elaboration of these primary data, not a saga of medical care. ” 5. Include significant negatives that helped you choose the most likely “diagnosis” on a differential list. They should be reported in your history of the present illness, along with the important positive answers: “Although Mr. White said that he felt severely depressed in the week since he lost his job, he denied insomnia, loss of appetite, and lack of interest in sex. ” 6.

Report your findings in plain language. Your readers may include people who are unaccustomed to the jargon of the mental health field. Short sentences and active verbs will demonstrate the clarity of your thinking. Avoid abbreviations other than commonly used ones. 7. The person is a person, not a case. It is considered bad form to refer to patients as “this manic” or “this schizophrenic”. Always strive to refer to your patient as “this person” or “this patient/client with schizophrenia”. Such wording helps to preserve the reader’s feeling for the humanity of your patient. II. e. Personal and Social History II.

e. 1. Childhood through Adult Life Chronological sequence is again very important in this section. Therefore, begin with birth and early childhood, and proceed through education, military experience (if any), sexuality, marriage, work history, legal history, and religion. You can use either a paragraph or outline style. In this section, strive to present a reasonably complete picture of your patient’s background. Even so, you should generally omit data already covered in the history of the present illness. Edit out the anecdotes and trivial details which patients invariably illustrate their life stories with.

You should include important negatives, such as the absence of childhood sexual abuse in a patient you suspect of borderline personality disorder. Also include important past positives, such as previous drug or alcohol abuse, which you have omitted from the history of the present illness because they no longer affect your patient’s life. II. e. 2. Family History It is important/useful to report the family history in a separate paragraph in order to emphasize the biological and environmental effects that families can have on the development of the adult individual. Include the data you have obtained for physical as well as mental disorders.

When reporting the mental disorders, be sure to include not just the diagnosis, but also whatever data you have obtained that would substantiate (or refute) that diagnosis. Moreover, if the patient was adopted or if the family history is completely negative, report so and move on. II. e. 3. Medical History Mention any operations, major medical illnesses, current and recent medications, and hospitalizations for reasons not related to mental health. Mention any habits such as the use of tobacco or alcohol. II. e. 4. Review of Systems Mention any positive responses to your questioning about past and present physical problems.

If somatization disorder has been a consideration in the differential diagnosis, list the symptoms you detected in that disorder’s specialized review of systems. II. f. Mental Status Examination For many patients, much of the mental status examination will be normal and can therefore be covered briefly. In describing your patient’s mental status, keep in mind which details would be needed to support or refute the “diagnoses” You should report not only positive information, but also the important negatives. Describe the patient’s general appearance and clothing; contrast apparent age with stated age.

Be sure to mention all aspects of affect with their lability and appropriateness. When you are trying to describe abnormalities, don’t use general terms such as “bizarre” or “peculiar”. Instead, take the trouble to choose words and phrases that are truly descriptive: Instead of “The patient’s clothing was strange” say, “The patient was dressed in a tutu and bodystocking hand-stitched from old flour sacking. ” Remember that written mental health records are legal documents. They can be cited by lawyers and requested by patients themselves, so make sure that your tone and wording will withstand scrutiny.

Avoid jokes, complaints, and any other comments that should be kept private. If you need to express an opinion that could be considered unpleasant, qualify the statement by admitting that this is your inference: “Her manner seemed seductive …” “He appeared to be intoxicated …” Moreover, be sure to mention any abnormalities of association, as well as rate and rhythm of speech. Use examples with direct quotes both to show the flavor of the patient’s speech and to provide a baseline for judging later change. The patient’s content of thought is another aspect you should describe briefly.

It will generally mirror what you have already mentioned in the history of the present illness: “The patient’s content of thought largely concerned his past infidelities and the fact that his wife was about to leave him. He expressed no delusions, hallucinations, obsessions, or phobias. ” When your patient has language deficits, state what they are, and also give an example of what you mean. In reporting cognitive abilities, it is not sufficient simply to mention that the patient was “normal” or “intact”. You should note that what tests you made (during a first session), the responses given, and how you interpret the responses.

In reporting insight and judgment, you will usually have to make an interpretation (such as excellent, good, fair, or poor), but be sure to cite your reasoning. III. Case Formulation In the case formulation, you attempt to synthesize all that has been learned about the patient’s past in order to point the way toward a better future. There are several reasons for preparing a formulation: To focus your thinking about the patient, to summarize the logic behind your “diagnoses”/decisions, to identify future needs for information and treatment, and to present a brief summary of the patient.

While doing a formulation, a number of formats can be used; some of them are so involved that they risk presenting again all the material you have just covered. The method presented here combines the advantages of brevity, completeness, and simplicity. A sample formulation is composed of the sections as follows: Brief Recapitulation, Differential “Diagnosis”, Best “Diagnosis”, Contributing Factors, Further Information Needed, Treatment Plan, and Prognosis. The two most important sections of the formulation are the differential diagnosis and the contributing factors.

They contain the original thinking you will do in putting together all the material you have collected. III. a. Brief Recapitulation Following some minimal identifying data, state the symptoms and course of the present illness as based on the facts in the history of the present illness and the mental status examination. Draw from all parts of your report (as needed): “Mrs. Johnson is a 27-year-old married woman with two previous hospitalizations for a psychosis that has been previously called schizophrenia.

For 3 weeks she has stayed in her room, fasting and ‘preparing for the end of the world,’ which she says she has caused. Her husband brought her to the hospital when he became concerned about her weight loss. ” III. b. Differential “Diagnosis” Each of the possible diagnoses in your differential listing is presented with the principal arguments for and against it. Consider Axis I and Axis II disorders. III. c. Best “Diagnosis” State the diagnosis you favor (disorder you suspect), why you have chosen it, and the authority (e. g. , DSM-IV). Note that your best “diagnosis” may not be the one highest in the hierarchy.

For example, a cognitive disorder must always be ruled out first, but it frequently is not the most likely diagnosis. III. d. Contributing Factors Here you describe how the various factors you have identified contributed to the development of your patient’s main problems. Where applicable, mention biological, dynamic, psychological, and social factors. Depending on the material you have identified, this section could be long or short. III. e. Further Information Needed Briefly cover interviews, tests, and records you may need to firm up the “diagnosis”/decision. III. f. Treatment Plan

Outline your recommendations for treatment such as psychological (e. g. , psychotherapy focused on feelings of guilt and grief) and social (e. g. , assistance with financial planning, education of the patient’s family regarding his/her disorder) III. g. Prognosis In order to declare the prognosis, the clinical psychologist asks the question of “What is likely outcome for this patient? ” “Mrs. Johnson is expected to recover completely. Psychological and social intervention plans may prevent subsequent episodes. ” IV. An Outline for the First Clinical Interview Report (Cansever, 1982)

In order to present you an outline for the first clinical interview report, I used the relevant sections (i. e. , section regarding the first interview) of psychological assessment report that was outlined in Cansever (1982) (pp. 270-271) and translated them into English. That is to say, I simply changed the title of the report and eliminated the sections regarding the discussions of psychological test results in order to emphasize the difference of first interview report from the report of a whole interview process (See in Appendix A).

In the outline of Cansever (1982), there is no section that assesses the risks of suicide and homicide; however, (as applicable) presence of ideation, plan, imminence, and risk levels of both suicide and homicide must be indicated. V. Some Issues to Be Considered in Report Writing If a psychological assessment (e. g. first clinical interview) is not employed under preferred/standard conditions, this should be noted in the report since it affects the symptoms of the patient. It should also be noticed that psychological assessment report cannot be a series of assumptions or vague statements.

That is to say, the idiosyncratic aspects/symptoms of the patient and causes of them must be reported confidently (Cansever, 1982). Furthermore, it should be noted that the psychologist must not only understand the person who has been the subject of his/her investigation, but he/she must know the degree of psychological sophistication of the recipient of the report (Stapleford, 1955). However, recent graduates indicated that they had not been taught to provide and explain data in a way understandable to non-psychologists (Harvey, 2006). In this website you can attain some further psychological report writing tips: http://www.

msresource. com/psy_rpt. html VI. Common Mistakes Made During Report Writing While writing a report, a clinical psychologist may fall into some errors: Generalizations regarding the patient (comments that are appropriate for anyone, like the ones in horoscopes), exaggerations of symptoms (dramatizations), ignoring the positive aspects/strengths of the patient, failing to notice symptoms that are appropriate to context or culture, reporting unnecessary information about the patient, and simplifying the richness of the patient’s psychological aspects and dimensions of his/her personality (Cansever, 1982).

VII. Summary All in all, via this presentation, I have tried to present you how to write a first clinical interview report by explaining the aims of report writing, organization of the written report, case formulation, Cansever’s outline, some issues to be considered, and common mistakes made in report writing. As a conclusion; I may contend that as you see in this picture, even if we have with the same inks with same amounts, we may end up with highly different paintings (i. e. , in our concepts: different assessments/reports).

However, I believe that through education and hardworking, it is possible that we will be able to create same or similar paintings/reports. VIII. References Cansever, G. (1982). Klinik psikolojide degerlendirme yontemleri. Istanbul: Bogazici Universitesi. Harvey, V. S. (2006). Variables affecting the clarity of psychological reports. Journal of Clinical Psychology, 62(1), 5-18. Morrison, J. (2008). The first interview. (3rd ed. ). New York: Guilford Press. Plath, F. W. , & McMath, J. C. (1979). Clinical hypocompetence: The interview.

Annals of Internal Medicine, 91, 898-902. Stapleford, E. (1955). Review of writing clinical reports. Canadian Journal of Psychology, 9(1), 59. Appendix A First Clinical Interview Report (Confidential) Name of the Referring Person Date of Issuance Address of the Referring Person Name of the Patient/Interviewee Age of the Patient/Interviewee Date of First Clinical Interview Duration of the First Clinical Interview (First Section) The reason/reasons for the patient to enter the assessment procedure The aim of the assessment (i.

e. , the first clinical interview) (Second Section) Description of the general appearance of the patient (e. g. , his/her physical health, clothing, motivation, reactions to be assessed, relationship with the clinical psychologist, cooperation, and salient characteristics of his/her personality) (Third Section) Mentioning the factors that has lead/contributed to the patient’s current complaint (e. g. , birth traumas, developmental disorders, physical illnesses, pathological processes within the family) (Fourth Section)

Explaining life conditions that are related to the aim of the assessment (The patients’ and the family members’ educational, vocational, marital, and socio-economic status; the relationships of the patient with his/her family members, friends, and the individuals in school or job; his/her attitudes, values, rules, future expectations; his/her adaptive and non-adaptive behaviors, the positive and negative effects of those behaviors on the patient and his/her family; the factors that increases and decreases the complaints) (Fifth Section)

Diagnostic impressions Explaining how positive and negative factors will change the future of the patient (i. e. , “onkestirim” estimation? ) (Last Section) Recommendations of the clinical psychologist to treat or reduce the symptoms of the patient (e. g. , medical or psychological treatment, educational interventions, etc. ) Sign of the clinical psychologist Note: This report has been written to help the specialist. It is crucial not to give the patient or his/her family overt information regarding its content.

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