How to Write the First Clinical Interview Report

3265 Words Mar 25th, 2014 14 Pages
PSY 531 Clinical Assessment – First Clinical Interview – Application

How to Write the First Clinical Interview Report
Begüm Zübeyde Şengül

Middle East Technical University
Department of Psychology
Clinical Psychology M.S. Program
2012-2013 Fall Semester

How to Write the First Clinical Interview Report
Communicating Your Findings to Others
Somewhere, sometime, as a mental health clinician we might conceivably do an evaluation and provide a complete course of treatment, or in our case, a complete document of first clinical interview of a patient. Regardless of where you work or who your patient may be, you will have to communicate your findings to someone. Working in hospitals, university counseling centers,
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When you are writing up the history of the present “illness”, keep in mind several rules.
1. This should be a chronological history. Like all good stories, this one should have a beginning, some development, and an ending. In most cases, it will begin with the onset of the first episode of illness. For example, it may be marked with an opening phrase like this: “Mr. Jackson was well until age 30, when he suffered the first of several episodes of depression.” In this single economical sentence, note that the reader is alerted to (1) the principal area of clinical interest (mood disorder: depression), (2) the age of onset, (3) the fact that Mr. Jackson’s problem is not a new one, and (4) the patient’s good health during the decade of his adult life prior to the onset of his illness. The additional information should proceed more or less chronologically, ending with the reasons that made your patient to enter the treatment at this time.
2. Support your best diagnosis/diagnostic impression/clinical conceptualization. This means that your writing should form a picture in which history, mental status, and possible diagnosis are mutually supportive portions of a consistent whole.
3. If the story is complicated, try to disentangle it. One way to accomplish this is to leave until later details that don’t support your best “diagnosis”. This less relevant information can be included later in the personal and social history. You can also present distinct themes

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