Patient Assessment Report Assignment Guidelines
Writing evaluations is an important aspect of clinical work. For this assignment, students will write the Patient Assessment Report based on Chapter 4 of the textbook, according to the expectations given in the assignment directions. Students should use the Sample Assessment Report in Appendix D of the textbook for examples to follow. However, please note that there are a few exceptions given in the assignment directions that are not in the Sample Assessment Report. The report should be written in paragraph style.
1. Select a fictional patient for the report
Students may use the fictional patients from the PHQ-9, GAD-7, or Trauma assignments for this report. Students may also choose to use the additional fictional patient provided with this assignment at the end of the instructions. Students may take liberties to supply additional information as needed for the sake of completing the report.
2. Demographic Information.
Students should include the following demographic information: Name, age, ethnicity and other relevant cultural concerns, marital status, sex, gender identity, or expression concerns as needed, such as transgender, choice of pronouns preferences.
3. Presenting Problem
Students will write a narrative, in paragraph form, giving a general description of the patient and expressing reasons why the patient presents for therapy. This should include symptoms, relationship challenges, environmental concerns, and other contributing factors.
In this section, identify the symptoms that you are using to diagnose the patient. Be specific about symptoms of trauma, depression, anxiety, personality disorder, etc. Put enough information into this section to justify your diagnosis. Make sure that you use DSM 5 symptomology to give evidence for the diagnosis. For example, for depression: “The patient reports finding it difficult to get to sleep and stay asleep nearly every night. The patient also reports that he has diminished interest in his favorite recreational activities, including…”. Again, students are allowed for the sake of this assignment to supply information as needed. You do not need to provide a “reason for referral”.
4. Family Background
In this section, write a narrative in paragraph form about significant factors from the patient’s family of origin as well as the patient’s current family situation. Address the patient’s relationships with his parents or primary caregivers, such as grandparents, etc. Also, report on the patient’s relationships with siblings during youth. Write about any significant occurrences or traumatic events experienced during the patient’s life. Discuss the patient’s relationships at present with his or her own children, spouse, and other significant relationships.
5. Significant Medical/Counseling History
In this section, address any physical maladies, chronic pain, psychiatric medications, psychiatric hospitalizations, or other matters about medical or therapeutic health that could impact the patient’s treatment. Identify periods in which the patient was treated in therapy for mental health concerns.
6. Substance Use and Abuse
Explore the patient’s involvement with alcohol, cannabis, cigarettes, and other substances. Examine any other behaviors such as eating issues, excessive gambling, etc. Ask the patient how much alcohol he or she consumes, how much cannabis is used, etc.
7. Educational and Vocational History
In this section, write about the patient’s experience in education as far as the level of education completed and discussion of types of education, such as college degrees or vocational skills training. Write about the patient’s current career as well as careers or types of work that the patient has done in the past. Explore with the patient current levels of satisfaction with employment.
8. Other Pertinent Information
Explore with the patient and write about any other issues, such as legal matters, criminal record if appropriate, issues related to sexuality, orientation, sexual dysfunction, and any financial challenges.
9. Conduct a Mental Status Exam
Use the information related to mental status exams given on pages 68-70. Use Table 4.1 to guide you in writing this. Do so as a narrative in paragraph style.
10. Suicidal Assessment
PLEASE NOTE! This section is not in the Sample Assessment Report, or Chapter 4 of the textbook! In this section, use the questions for suicidal assessment from the Columbia Protocol (C-SSRS). They can be found at the link below. For the sake of this assignment, we will assume that the fictional patient is not presently susceptible to suicidal behavior.
The Columbia Lighthouse Project. (2016). The Columbia Protocol (C-SSRS): About the Protocol. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
11. Assessments Identified for Patient
PLEASE NOTE! This section in the assignment directions is different than in the Sample Assessment Report in the textbook as well as in Chapter 4.
For this section, you will select at least 3 tests or assessments from the course textbook to administer to the patient. State specifically what these tests are. Explain the goals of these tests. Also, provide a rationale for why these tests are being chosen for the patient to take. You do not have to report any results from the tests.
12. DSM 5 Diagnoses
Based on the symptoms identified and conveyed in the Presenting Problem, offer a diagnosis of the patient. Use DSM 5. Provide an F code. Write out the name of the disorder in full, the F code, and any specifiers as needed. It is acceptable for the patient to be comorbid, or to have co-occurring disorders, such as PTSD, Major Depressive Disorder, Generalized Anxiety Disorder, etc. A file containing DSM-5 has been made available with the course materials.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
13: Summary & Conclusions
Write a concise narrative that integrates briefly and succinctly the essential information regarding the patient coming from the report. There should be no new information given in the summary.
Fictional Case Study: Patient Assessment Report Assignment
Personality Disorder
Amelia is a 23-year-old woman, cisgender, single, no children, who lives with her parents, who are married and in their mid-50’s. Amelia has a high school diploma and works in a manufacturing facility full-time. “I cannot believe the way people treat me! I get into a relationship and it seems great. Then, it’s horrible! I make friends for a while but they never last.”
Amelia has had 5 romantic partners in the past 3 months. “I know it seems like a lot”, she says. Amelia shares how she finds a new romantic partner and finds herself “head over heels in love! It is like the guy is the greatest person in the world. I feel amazing.” It is not very long after the relationship starts that Amelia finds that her positive feelings leave. “Then he will do something that makes me mad! I think, how can he be such a loser!” Amelia shared how recently she had wanted to spend the evening with her latest partner but he told her he needed to spend some time with friends away from her as a break. “Can you believe he said that to me? I felt so hurt. I hate being alone. What is wrong with me? Here I am excited about our relationship and he abandons me. I got so mad at him for that.”
Amelia then describes how she argued with her boyfriend after that. The argument became quite heated. She was at his apartment. Neighbors complained to the police. Amelia admitted that in her anger, she threw a vase across his apartment. “This happens with every guy I find”, she says. Amelia describes how she goes from feeling very happy to having fits of rage with them. “They try to control me, or get away from me. Why does it have to be like that?”
Amelia shares that her latest boyfriend told her that he could not handle this type of volatility in their relationship. “I cried and screamed. I told him, ‘you can’t leave me! You can’t leave me!” Amelia shared that she has a hard time accepting herself, or feeling worthwhile unless she has a significant other in her life. “Without a boyfriend, I feel horribly empty and alone. I don’t really know what my life is all about.”
Amelia shared how she often tries to “completely re-do myself!”. She colors her hair very bright colors and buys flashy clothes of unusual styles. “I am just trying to figure out who I am”. She also shared that it is not unusual for her to go on spending sprees, maxing out her credit card. Her parents have frequently bailed her out in these situations. “I tend to drink way too much, too.” Amelia describes how when she drinks she often argues more. She also tends to engage in much more risky behavior such as gambling to excess.
Amelia shares, “I sometimes feel like there is no way out of this mess I am in.” I get so mad and I just cannot dial it back.” She shared that she has engaged in cutting and self-harm before in her life. There have been times when she seriously considered taking her life. “I don’t know if I could actually do it, but sometimes it seems like the best option”.
