Chapter 4: Assessment report process Flashcards
assessment report
deliverable or end product of the assessment process
breadth
casting a wide enough net based on reason for report
depth
assuring one is using techniques that reflect the intensity of issues being examined
structured interview
responds to reestablished questions/prompts
offers broad enough areas of content to cover topics a practitioner a person may otherwise miss or forget to ask; ensures examiner will cover all items (ensure breadth)
increases reliability of results by ensuring all prescribed items covered
drawbacks: doesn’t always allow for depth, may miss info b/c items predetermined and less likely to follow up, can’t go off hunch, client may experience interview as dehumanizing, potential for misinterpretation or unfamiliar w items
unstructured interview
responds to open/unstructured items
creates more conducive atmosphere to building rapport, allows client to feel like they are directing interview and items they deem important
greater depth of information
drawbacks: may miss info because caught up in client’s story instead of prescribed set of questions, may spend more time on items that preferred
process of clinical interview
- informed consent
- behavioral observations
- mental status exam
- risk assessment
appearance and behavior
=observable appearance and behaviors during the interview
- dress
- hygeine
- body posture
- sig noverbals
- manner of speech
emotional state
affect and mood
thought components
thought content: addresses whether client has delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideations, etc.
thought process: circumstantiality, coherence, flight of ideas, logical thinking, intact vs. loose associations, organizations, tangentiality
cognition
orientation to time, place, person
short and long term memory
eval of knowledge base and intellectual functioning
statement about level of insight and ability to make judgements
suicide risk assessment
part of thought content
evaluating risk factors and warning signs
risk factors: ongoing client CHARACTERISTICS that increase suicide risk
warning signs: client BEHAVIORS that warn of suicide risk
SLAPP
- Specific details in plan
- lethality of proposed method
- availability of proposed method
- proximity of helping resource
- previous history or attempts
choosing the appropriate instrument
identify type of information needed
identify available information
determine methods for obtaining information
search assessment resources
choose!
demographic information
basic info: name, age, address, phone, email, etc.
presenting problem or reason for referral
why individual came to counseling, why examiner asked to do assessment
