Dates of Evaluation: 9/12/96
PURPOSE FOR EVALUATION: Rather than "Reason for Referral" the first section for the report is better called "PURPOSE FOR EVALUATION." This gives you a lot more flexibility. If you use "Reason for Referral", you pretty much have to copy whatever the consult says. Unfortunately, many consults ask questions which tests can't answer (or else they don't ask any question at all).
Use this section to briefly introduce the patient and the problem. Begin with a concise "demographic picture" of the patient. (e.g., This is the third inpatient admission for this 32 year old, single, white female who has 13 years of formal education and is employed as a beautician. She was admitted due to symptoms of major depression with possible psychotic features.)
Use this section to tell your reader what issues you will address in the body of the report. In this way, he won't get to the end of your report, then have to think back to decide whether your conclusions were supported by your data. He'll know on what issues to focus, and he can be forming his own impressions while he's reading. (e.g., The purpose for the current evaluation was to screen for evidence of psychosis and clarify the nature of the underlying depressive disorder.) In sum, use this section to "pose a question," which you will answer in the "SUMMARY" section.
Finally, if the evaluation takes more than 5 days to complete, you should put a progress note in the patient's chart giving preliminary test results. For example, you might conclude the "PURPOSE FOR EVALUATION" section of your report with, "Preliminary results were reported in the patient's progress notes on 9/13/96. The current report will supplement and elaborate upon those preliminary findings."
ASSESSMENT PROCEDURES: Refer to this section as "ASSESSMENT PROCEDURES" rather than "TESTS ADMINISTERED." This allows you to include the Mental Status Exam and the Clinical Interview as two of your procedures. This also helps communicate to referral sources that you do more than give some tests and copy interpretive statements out of a manual. It lets them know that your evaluation is a professional integration of information from a variety of sources. Be sure to also note who gave the tests and how long it took. These issues are important if a case ever goes to court.
e.g.: Millon Clinical Multiaxial Inventory-III (MCMI-III)
This patient participated in 3 hours
of testing and a 1 hour diagnostic
BACKGROUND INFORMATION: In this section present paragraphs dealing with family, social, legal, medical, family mental health, etc. issues, if needed. Only include those issues that are relevant to the "questions" posed under "PURPOSE FOR EVALUATION." Excessive, unnecessary details will distract the reader from the case you are trying to build in support of your conclusions! Whenever possible, MAINTAIN CHRONOLOGICAL ORDER when presenting background information.
Next describe the patient's history of substance abuse/mental problems, and mental health care in CHRONOLOGICAL order. Where possible, provide enough details of prior intervention efforts to clarify what was attempted and whether it was successful. Your goal is to encourage replication of prior successes and/or avoid duplication of prior treatment failures. Also, be sure to describe the patient's behavior and level of adaptive functioning BETWEEN prior interventions. These details will help give the treatment team an idea of what "target level" of adaptive functioning to shoot for in the current intervention. Follow with a paragraph describing the onset and development of the present illness/ exacerbation. Let the reader get an idea of how the current admission compares to prior admissions and what specific events precipitated the current admission. End this section with a brief paragraph summarizing staff observations, patient behavior, level of motivation, etc. during the current admission. Keep in mind that objective observations by professional staff are one of your best sources of data. Conclude with a sentence indicating medications being taken at the time of testing.
MENTAL STATUS EXAMINATION: Focus on YOUR observations and impressions. This section of the report should focus on your objective evaluation. Avoid quoting the patient's opinion of his own mood, affect, etc. It's also best to avoid mixing in background information or test information with this section. A typical MSE for a 'normal' patient might read:
The patient's attitude was open and cooperative. His mood was euthymic. Affect was appropriate to verbal content and showed broad range. Memory functions were grossly intact with respect to immediate and remote recall of events and factual information. His thought process was intact, goal oriented, and well organized. Thought content revealed no evidence of delusions, paranoia, or suicidal/homicidal ideation. There was no evidence of perceptual disorder. His level of personal insight appeared to be good, as evidenced by ability to state his current diagnosis and by ability to identify specific stressors with precipitated the current exacerbation. Social judgment appeared good, as evidenced by appropriate interactions with staff and other patients on the ward and by cooperative efforts to achieve treatment goals required for discharge.
Specific tests are rarely mentioned by name. For example, information from scale 2 on the MMPI-2 may be combined with interpretive data from the MCMI-III dysthymia scale. If the integration of this information is consistent with the history and the mental status exam, it is included in a paragraph dealing with depression.
The strength of this model lies in its efficiency and concise focus on the referral problem. The reader isn't distracted by unrelated details. The primary weakness of the model is that you don't report some of the information which is unrelated to the "PURPOSE FOR EVALUATION" but which could potentially be useful to other disciplines.
SUMMARY/RECOMMENDATIONS: Begin by specifically answering the questions you posed under "PURPOSE FOR EVALUATION." Then elaborate as much as needed to present your conceptualization of the case. It's fine to include DSM diagnostic impressions, but your summary of the patient's psychological makeup is far more important. If you do include DSM labels, be sure you've provided enough detail in the body of the report to support the diagnostic criteria as described in DSM. Any recommendations for treatment can also go here. For example:
It is recommended that efforts to establish a trusting relationship with this patient be continued, in order to help him cultivate a more adaptive coping/defensive pattern. Individual therapy will be more productive than group interventions. Once his guardedness has been relaxed, it will likely be beneficial to explore psychosocial issues present at the time Mr. Jones lost his job, as these appear to have partially precipitated the current psychotic exacerbation. Additionally, the patient will benefit from encouragement to explore the social and adaptive significance of his substance abuse history.
Please let me know if any additional information is needed concerning the results of this evaluation.