1. Case Summary

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.)

OTHER FACTORS:

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.

3. Recommendations 

Explain any recommendations for interventions, treatment, and/or disposition.

4. Questions

Address the specific questions that were asked in the instructions for this assignment.

Here is a sample assignment question and an appropriate brief response:

Question: Describe what further information you would need to accurately diagnose this case.
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