Psychological report writing /CLINICAL PSYCHOLOGY REPORT

Psychological Report Writing / Clinical Psychology Report Format

 

        Psychological Clinical report taking is a formal way to dig into the client’s problem for the purpose of solving it.

The students of psychology often do not know how to take a report or how to write it. 

Here I will discuss with you a proper method through which you can follow to get details from the client to reach the problem and how to write the clinical psychology report 

Important Components of the Clinical report writing are;

1. Demographics
2. Presenting problem
3. History of the problem
4. Prior treatment
5. Medical history
6. Family history
7. School history
8. Work history
9. Psychosomatic complaint
10. Addictions
11. Family psychopathology
12. Personality traits
13. Interview behavior
14. Orientation
15. Sleep
16. Attention
17. Perception
18. Thoughts
19. Affect
20. Behavior
21. Mannerism & posturing
22. Diagnosis 

Demographics

Demographics includes name, date of birth, gender, race, appearance, education, siblings, earning members, language, marital status, informer name, and intake by. Sometimes it happens that the client does not want to share his/her personal information like name race, family information, etc. In this case, despite the name, we will write XYZ and family information will take in another way.

            Name is not important. Religion and education are important sometimes the root of the problem lies here. Marital status, earning members, financial problems may be a stressor.

Presenting Problem

This means the nature of the problem.

·         What is the problem or what are the symptoms? Do not use the specific diagnostic terns like depression instead of this we can write a person feeling low, have fatigue.

1. ·         Feelings of the person related to symptoms and problem
2. ·         Thoughts of the person related to the problem
3. ·         Events before this particular problem
4. ·         What are the feelings and thoughts person have about self.

History of Problem

1. ·         Duration of the present problem
2. ·         Change in nature of the problem, when the intensity of problem high or low
3. ·         Other psychological problems
4. ·         No of attacks
5. ·         Intensity of attacks

Prior treatment

Is person take any type of treatment of this presenting complaint, if yes then

1. ·         Ask for the details and then note down it.
2. ·         When and for what duration treatment continues
3. ·         From whom treatment is taken before
4. ·         Name of drug used by the client either prescribed or non prescribed
5. ·         ECT shock is given OR NOT
6. ·         Any type of help taken from the religious person(faith healing).
7. ·         Responses to treatment either positive or negative

Medical History

·         Asked the client about, most recent physical Exam (sugar test, etc.). what was the date of the result?

·         Current medication used by the client

·         What is the health condition of the client since childhood

·         Detail about serious illnesses(disability or surgery).

·         Eating and sleeping habits of the client.

Family History

·         Number of siblings

·         Birth order of the client

·         Earning member of client family

·         Migration of family

·         New birth in the family

·         Marriage in family

·         Serious illnesses in the family

·         Deaths in family

School history

1. ·                         Marks/divisions obtained,
2. ·                             the school changed,
3. ·                             school problems,
4. ·                           relationship with peers and teachers,
5. ·                     extra-curricular activities

Work History 

1. ·         Nature of job held and salary,
2. ·         If changed the  job then reasons for job changes,
3. ·         relationship with juniors, colleagues, and bosses

History of friendship 

1. ·         Nature and extent of relationships,
2. ·         recreational activities,
3. ·         degree of religiosity,
4. ·         sexual history, premarital, marital, and extramarital sexual relationships

Psychosomatic

1. ·         Obesity,
2. ·         headaches,
3. ·         pain full menstruation,
4. ·         skin disorders,
5. ·         asthma,
6. ·         ulcers, nausea, and vomiting

Addictions 

1. ·         prescribed and non-prescribed medication,
2. ·         narcotics use, smoking, pan/tobacco chewing, alcohol use,
3. ·         gambling

Family psychopathology

Nature, history, and treatment of mental disorders in family members of patient's family

Personality Traits 

1. ·         Schizoid(want to live lonely)
2. ·         Paranoid(suspiciousness)
3. ·         Schizotypal(distress in building relations)
4. ·         Antisocial(don does not follow the rules and regulation of society)
5. ·         Borderline(indifferent attitude towards self-based on the environmental cues, harm to self)
6. ·         Narcissistic(extreme self-love)
7. ·         Histrionic(show attention-seeking behaviors)
8. ·         Avoidant(because of fear of criticism avoid the social situation)
9. ·         Dependent(depends on others for even small tasks)
10. ·         obsessive-compulsive(have strict rules and regulation for self)
11. ·         passive-aggressive(do not show aggression, suppress the feelings).

Interview Behavior 

Open, secretive, anxious, relaxed, withdrawn, cooperative, timid, aggressive, compliant, opposite. Write all this.

Orientation 

Ask the client about

1. ·         person,
2. ·         place,
3. ·         time

this information can get through Mini-Mental Status Examination

Sleep 

• ·         Insomnia(sleeplessness)
• ·         Hypersomnia
• ·         nightmares,
• ·         sleepwalking

Attention 

            Concentration, memory. This can also find through Mini-Mental Status Examination

Perception 

1. ·         illusion,
2. ·         hallucination: auditory, visual, tactile, somatic, and olfactory

Thoughts 

Unusual, content including suspiciousness and delusion, conceptual, disorganization including losing of association, suicidal thoughts.                       

Affect 

Crying enchantments, sadness, blame feeling, hopelessness, suicidal thoughts, eagerness, anger, impressiveness, dull affect

Behavior 

Speech, mute, talkative, abusive, restless, assaultive, destructive, excited, motor retardation

Mannerism and posturing 

unusual gestures, preservative movements.

Diagnosis 

Based on all the above symptoms and stressor identify and diagnose the problem.

 

 

By following all these steps client's history was taken,  which you can read here "Psychological Report Writing Sample/ Clinical Psychology Report Format Sample.