Week 5 - Report Writing Flashcards
10 functions of case conceptualisation according to kuyken, padesky and dudley
- Synthesizes client experience, CBT theory, and research
- Normalizes presenting issues and is validating
- Promotes client engagement
- Makes numerous, complex problems more manageable
- Guides the selection, focus, and sequence of interventions
- Identifies client strengths and suggests ways to build client resilience
- Suggests the simplest and most cost-efficient interventions
- Anticipates and addresses problems in therapy
- Helps understand non-response in therapy and suggests alternative routes for change
- Enables high quality supervision
Reports
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Reports are a permanent record of
- Consultation (s) with a client
- Client status at a particular point
- Your professional opinion
- Reports consolidate & communicate information
- There are considerable ethical & professional issues associated with reports
Access to Reports: APS Guidelines
The information contained in the file is confidential information provided by the client to the psychologist and should not be disclosed to a third person without the consent of the client.
The psychologist will normally restrict the information recorded in the file to essential factual data. Where assumptions are drawn from that data they must be clearly identified as assumptions of the psychologist and not information provided by the client.
A situation may arise where a client informs the psychologist of a criminal action or an intended criminal action. See APS Guidelines on reporting child abuse and neglect, and criminal activity
Reports – APS Guidelines: Client Records
Keep only records necessary for optimal service delivery to the client and efficient provision of psychological services
Ensure confidentiality => storage, access and disposal of records, subject to the legal requirements of their employment conditions
Maintain adequate records of administrative activities (e.g. retaining copies of correspondence, minutes of meetings and other documentation => future reference for self & other psychologists who may take over a case
Make appropriate response to every referral received (i.e. keep record of referral and action taken) => client (where appropriate) and referring agent are informed of outcome of referral
Maintain adequate records of all contacts with each client and with others (e.g., staff, relatives) involved with the client, indicating date, time and place of attendance, those present and the nature of the service provided or action taken
Writing reports
purpose / style
Purposes of Report can vary e.g.,
- -Respond to referral question
- -Provide initial summary & indicate professional opinion re. dx & treatment plan
- -Provide summary of contact
Style can vary e.g., Clinical vs Medico Legal
Writing Reports (audience, length, clarity)
Be mindful of the intended reader (e.g., referring agent vs clinical summary for psychology clinic)
Vary length & language accordingly
Aim to convey necessary information only (remember, people are busy!!) and use headings to assist
Reports
expression and language
Aiming for professional tone e.g., avoid colloquialisms
Can use client’s own words (sparingly) – but put quote marks to signify
Use “action-oriented” language e.g.,, tie to specifics of behaviour
Watch spelling & grammar
Aim for logical, consistent flow
Make clear the difference between fact and speculation (for the latter, use qualifiers)
Reports
formats/headings
Formats/Headings… these can vary considerably but all need demographics e.g., CONFIDENTIAL PSYCHOLOGICAL REPORT Date of Report: Age: Date of Final Session: Client’s Name: Date of Birth: Date of Initial Session: No. of sessions:
Reports: Demographic/Identifying Info
Referral source/reason Gender, age, ethnicity Occupation (f/t, p/t) Relationship status Family organisation ---Any children, custody arrangements if not intact family Living circumstances
Report
Presenting Problem
What is it/are they? Write them in order of importance, according to client
What thoughts, feelings & behaviours are seen as problems by the client?
For each PP: duration, frequency, intensity & impact on functioning
Under what circumstances do they occur/not occur? Are there patterns of the problem?
Include examples of thoughts/behaviour where relevant (but not a narrative of the session!)
Stating the absence of a symptom may be important depending on context
- –Eg absence of suicidal ideation if reporting depressive symptoms
- –Consider diagnostic relevance – if binge eating, important to say whether compensatory behaviours are present
Reports: Presenting Problem(s)
what not to include
Do NOT include ANY history in this section – only what is currently occurring for the client
Do NOT include your interpretations: save this for the conceptualisation
Do NOT include a diagnosis (this is a separate item in the report)
But PP should inform your diagnosis – so, does your PP section contain enough info to fulfil criteria?
At this point, the reader should be able to turn to the diagnosis & not be surprised
What the client reports NOT what you observe (this does belong in MSE)
History of presenting problem
Here you are talking about how the issues the client has presented with have changed or stayed the same over time
How long have pp been present?
Chronicity, duration, trigger of all PP(if known)
Any historical triggers for PP
Fluctuations over time, any periods of remission
Must include history of ALL presenting problems
Present history in same order as PP
ONLY include history of PP, not other background history
History of PP likely to be important for diagnosis
—–Does the history justify your diagnosis?
Presenting problem
symptoms vs diagnoses
Only list symptoms NOT diagnoses – you haven’t diagnosed at this point
Only list symptoms that are occurring NOW – you are trying to tell the reader what they PRESENTED with
From this section, the reader should be able to turn to the dx section and NOT be surprised by what they find there!!!
History
You may use a range of headings according to nature & length of report
Family History
Developmental History
Educational/Occupational History
Drug & Alcohol; Forensic
Medical History
Relationship History
Treatment History
What is relevant vs. what you think is really interesting. What does the reader NEED to know to understand this client?
Aim to be succinct (highest risk of waffling in History)
Assessment & Results
All relevant assessment measures used
Include client’s score & clinical categories
Can include table or graph of scores over tx
If very complex (e.g. cognitive/neuro), consider adding as an appendix, provide summary in body of report
If validity of scores are questionable, make reference this
—“These results should be interpreted with caution due to…”
Discuss any inconsistencies between results, if results inconsistent with presentation/self-report, or between informants (parents, parent/teacher)
