General Format for Clinical Case Presentations

 

The purpose of creating a case presentation is to allow you to demonstrate an example of your current field work experience and to simulate the process of collegial psychological case consultations and the professional treatment planning process.

General Format for Clinical Case Presentations

This format is for your use in creating a case presentation for 8871 – Practicum. The purpose of creating a case presentation is to allow you to demonstrate an example of your current field work experience and to simulate the process of collegial psychological case consultations and the professional treatment planning process. This format should help you summarize your case in an organized and sequential manner such that your readers can develop a solid sense of the case you are presenting and the work you have been doing in you field experience.

NOTE: Please assure that all matters associated with confidentiality are strictly adhered to in your case presentation.

1. Demographic description of client

This section should be brief but it should leave your audience oriented to the basic demographic information about your client. For example: age, gender, SES, ethnicity.

2. Presenting problem and reason for referral

A. Client’s perspective

B. Family perspective (if applicable)

C. Referring agency (or individual’s) perspective (school, legal, other agencies, etc.)

D. A summary of differences between these sources if applicable.

3. Focus of treatment

Briefly summarize the problems you and your client are addressing in treatment. These may not include ALL of the problems listed in the reason for referral, or all of the presenting problems. However, if you are not addressing them yourself, be prepared to tell us what the disposition of those problems has been. In other words, did you make community referrals for other services, etc.

4. History of the presenting problem

Think in terms the course of the problem(s) over time:

Remember that you are telling a kind of a story about your client. The events of the client’s problems unfold in a specific sequence. This sequence is referred to as the clinical time course or chronology. Think of it as the scaffold on which all the other details of the history of the problem(s) will hang. Elements of the time course should include:

· When did the problem(s) start? (Onset)

· How has it progressed over time?

· What is its current status?

Once you’ve established the time course, note any factors that :

· make the condition worse

· relieve the condition, or make it improve

· Also – Note any prior treatments for the condition(s) and the condition’s response to those treatments

5. Brief initial mental status exam results

This is critical for inpatient clients. It is optional for other clients unless there are clear problems in certain areas that need to be delineated for your audience in order to have a more complete picture of you client.

I. General description

A. Appearance

B. Behavior and psychomotor activity

C. Attitude toward examiner

II. Mood and affect

A. Mood

B. Affect

C. Appropriateness

III. Speech (rate, quality, etc.)

IV. Perceptual disturbances (hallucinations – visual, auditory, tactile, olfactory)

 
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