1. Case Summary
- Provide a brief summary of what you have learned about the individual reviewed in the case. Include information about the individual in terms of demographics and general history, and the sources of that information, and the reason that the individual was referred, and by whom.
- Summarize any information you may have about evaluations that have been conducted, including the results.
2. Clinical Impression (Diagnosis)
Write the clinical impression in the DSM-5 format:
XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).
(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)
Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.
Explain any recommendations for interventions, treatment, and/or disposition.
Here is a sample assignment question and an appropriate brief response: