Psychiatric Assessment Report/Treatment Plan (Guidelines for Completion)
Section 1 - Introduction
1. Introduction
This section should outline the circumstances of the assessment and should identify the specific questions that the assessor has been asked to address. These questions should come directly from the letter of referral. If particular problems were encountered in the process of assessment, then these should be outlined here.
2. Sources of information
All sources of information used in undertaking the assessment should be listed (and numbered here). These should identify the nature of the information (document, interview etc), the origin or author of the information and the date of the information. If undated, this should be identified. Information that is known to be available, yet not available to the assessor, should also be acknowledged here.
3. Confidentiality and competence
Assessors should acknowledge explicit consent (having seen written consent given to the case manager) as well as recording any concerns about competence to participate in such an assessment, if appropriate.
Section 2 - Background information
4. Client details
The client’s demographic and general social circumstances at the time of assessment are identified here. Where other people accompanied the client, their name and relationship to the client should be noted here. Some authors may include this information in some other section of their report.
5. Summary of relevant background history (leading to assessment)
This can often include a summary of historical issues or any other significant issues and serves to set the platform for the assessment. This may include an account of the accident/injuries and any other clinical issues of significance that might set a context for the current assessment.
6. Presenting problems and relevant background history
It is important to identify complaints made by the client and to give a comprehensive account of any clinical signs or symptoms described. It is also important to record any resultant impairment or disability and the extent to which each impair full rehabilitation for the client. It can sometimes also be helpful to comment on any other assessments that might have been previously completed and identify where (if at all) the client’s account of events differs. It is important to clearly and accurately reference information outlined in this section.
7. Past psychiatric/psychological history
Any past psychological and/or psychiatric history should be summarised. It is important to give a clear account of the times treatment was received, what the treatment was, what were its effects and what, if any, were the identified problems.
8. Past relevant medical history
Include any past medical history if it is relevant to this referral.
9. Current medications and dosages
List all current medications and dosages and any relevant past medication.
10. Alcohol and drug history
A full alcohol and drug history should be recorded, including the nature, frequency and amounts of any alcohol and substances that might be used and the pattern of use, over time. It is also important to record whether the client describes any symptoms or signs of abuse or dependence, what problems their alcohol or drug use may have caused them, whether they have accessed previous treatment or rehabilitation programmes and whether these were successful. It is particularly important to record the current pattern of use and what difficulties this might be causing the client in areas that might be important for occupational rehabilitation. If a diagnosis of any alcohol or drug related problem is made in the opinions of the report then please include the raw data supporting such a diagnosis.
11. Family history
Where appropriate, a summary of family relationships and functioning is useful. Any family history of psychiatric/psychological or alcohol or drug problems should be recorded.
12. Personal history
A general summary of the client’s personal history is important. If any psychiatric/psychological disorders are identified in the opinions then a more comprehensive account of the personal history is appropriate. Assessors should take care to only record personal information that is clinically relevant and not to record irrelevant information that may be embarrassing to the client. Possible information includes childhood and early development, schooling, friendships, intimate relationships, occupational history, adult relationships, children, pastimes and activities.
Information on occupational functioning and any changes over time should be recorded in detail.
13. Cultural/spiritual identity
Clients may identify very strongly with a cultural, spiritual or religious movement. Where appropriate, this should be identified and recorded, particularly if it presents difficulties for a client’s rehabilitation.
14. Summary of previous tests or assessments
Assessors may find it helpful to identify other tests that may have been undertaken previously, particularly if there were findings relevant to the current assessment. This is also an opportunity to identify other tests that may be helpful in further clarifying aspects of the clients presentation.
Section 3 - Diagnosis
15. Personality assessment
Clinical and/or standardised testing may be undertaken to identify relevant aspects of personality function. Assessors should take care to resist making derogatory or premature comments about personality function on the basis of one isolated interview.
16. Mental state examination (MSE)
A full mental state examination should be undertaken and relevant findings recorded in each report. This should include all areas of a MSE, using an accepted format with a comprehensive account of any relevant abnormal phenomena. It should also include a comment on suicidality or any thoughts of harm towards others, a comment on cognitive function and assessment of insight and judgement.
17. Formulation/summary
The psychiatrist should attempt to summarise all of the positive and any significant negative findings, as they are relevant to aspects of the client’s psychosocial and occupational rehabilitation. Assessors should particularly address any issues that might inhibit rehabilitation. This need not be long but should encompass aspects of the individuality of this person as distinct from any other.
18. Diagnosis
Assessors should outline any formal psychiatric/psychological diagnoses that they think are appropriate and reference them clearly to an accepted international system of classification (International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders DSM-IV).
19. Risk assessment
Where appropriate, a risk assessment should be undertaken and referenced to an accepted method of conducting such assessment (ie HRC 20, static and dynamic risk). This assessment should formulate risk and identify any particular situations in which the client may present issues of risk, including ways in which these risks can best be monitored and mitigated.
20. Opinions addressing the specific questions posed in the referral
It is often helpful to sequentially list each of the questions from the referral letter and address each in turn. Opinions should be adequately supported by other evidence outlined earlier in the report and should be clear and succinct.
Section 4 - Proposed treatment
21. Proposed treatment plan
Recommendations for treatment should be listed and specifically identified. A standard approach to aspects of treatment would involve any biological, psychological, social, cultural or spiritual interventions that might be of assistance in assisting with the client’s rehabilitation. Types of treatment and suggested timeframes should be stated along with a general comment on short and long-term prognosis. All recommendations for treatment should be able to be supported by the current evidence and be consistent with best psychiatric practice, given the circumstances.