Objectives of Case Report
- record important info in systematic way
- understanding of client's illness
- communication with others about the client
Functions of Case Report
- comprehensive account of client's illness
- reference for the clinician
- vital communication tool
Parts of Case Report
1) The Case History
a. Identifying Data
- demographics, referral details, central issue
b. History of the Present Illness
- with associated symptoms
- chronological problem (when did start? How it progress? What's happening now?)
- main problem
- effect of illness in client's life
- treatment (if any)
- psych illness and current medical status
c. Past Psychiatric History
d. Past Medical History
e. Family History
- parents
- family atmosphere, tension, stress
- family history of psych illness
f. Personal History (Anamnesis)
- early dev. complications
- childhood
- acad performance
- adolescence
- occupation
- menstrual history
- sexual history
- marital history
- children
- habits
- forensic history
- leisure
- social network
2) Mental State Examination - with psych rating scales
3) Multi-Axial Diagnosis (DSM IV-TR only) & Differential Diagnosis
a. Axis I - clinical disorders
b. Axis II - personality disorders
c. Axis III - physical disorders
d. Axis IV - psychosocial / environmental problems
e. Axix V - global assessment of functioning
4) Prognosis
- possible outcome of client's condition
- varies from full recovery
5) Biopsychosocial Formulation
- set of educated guess, hypothesis
- connections between biological, psychological, and social aspects of the client
6) Comprehensive Treatment Plan
a. Short-term Goals
- clarification of diagnosis
- medical management
b. Long-term Goals
- ongoing treatment
- vocational problems
- assessment of deficits and strengths
