patient case conceptualization report example

Sample Case Conceptualization Report Decent Essays 663 Words 3 Pages Open Document PRESENTING PROBLEM The patient reported having feelings of depression and anxiety since a recent job change that occurred six months ago. She also expressed feeling overly emotional in stressful situations for the past six months.

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How do you write a case conceptualization?

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life. Decide which events or factors are significant enough to include in a case conceptualization. When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.

What is the importance of case conceptualization and treatment planning?

What are case conceptualization and treatment planning, and why are they important in Brief CBT? Case conceptualization is a framework used to 1) understand the patient and his/her current problems, 2) inform treatment and intervention techniques and 3) serve as a foundation to assess patient change/progress.

How do you avoid multiple diagnoses in a case conceptualization?

Take care to avoid over-assigning multiple and potentially overlapping diagnoses. When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life. Decide which events or factors are significant enough to include in a case conceptualization.

How to write a patient case analysis?

Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information.

What is an example of a case conceptualization?

Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition).

How do you present a case conceptualization?

4 Things to Include in Your Case FormulationSummary of the client's identifying information, referral questions, and timeline of important events or factors in their life. ... Statement of the client's core strengths. ... Statement concerning a client's limitations or weaknesses.

What are the 3 goals of case conceptualization?

Case conceptualization is a framework used to 1) understand the patient and his/her current problems, 2) inform treatment and intervention techniques and 3) serve as a foundation to assess patient change/progress.

What are the 5 ps In formulation?

What should a formulation comprise? The 'Five P's' approach to formulationPresenting problem. ... Predisposing factors. ... Precipitating factors. ... Perpetuating factors. ... Protective/positive factors.

What are the four steps in the case conceptualization process in order?

Observing, assessing, evaluating, and collecting information about the client's presenting situation.

What does a case formulation look like?

A case formulation should provide a coherent summary and explanation of a client's symptoms and problems. It should include the following components (Persons, 2008): Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.

How do you write conceptualization?

Conceptualization involves writing out clear, concise definitions for our key concepts. Sticking with the previously mentioned example of masculinity, think about what comes to mind when you read that term.

What is the difference between Case formulation and case conceptualization?

Case conceptualization will be referred to as the explanation for a client's presenting problems. Case formulation will reference the process by which a case conceptualization is developed or formed.

What is case conceptualization PDF?

The case conceptualization (sometimes called a case formulation) is the clinician's collective understanding of the client's problems as viewed through a particular theoretical orientation; as defined by the biological, psychological, and social contexts of the client; and as supported by a body of research and ...

How do you write a good clinical formulation?

It should always include the following: (1) a discussion on the diagnosis (2) aetiological factors, which seem important, as well as taking into account (3) the patient's life situation and background, with (4) a plan for treatment and (5) an estimate of the prognosis.

Is the 5Ps a CBT formulation?

The 5Ps is however commonly associated with the CBT model, in line with Johnstone and Dallos (2014). Therefore, for our example, I will use this Biopsychosocial idea and draw on a range of different underpinning approaches, however coming predominantly from a CBT perspective.

What is a formulation report?

A formulation is a joint effort between you and the psychologist to summarise your difficulties, to explain why they may be happening and to make sense of them. It may include past difficulties and experiences if these are relevant to the present. It acknowledges your strengths and resources.

What is a patient case study?

Writing Your Patient Case Study. Since patient case studies are generally descriptive, they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights.

Why do medical practitioners use case studies?

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

What is a case study?

Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

How do case studies make a difference in the medical arena?

Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

Can you generalize a population using one case study?

You cannot generalize a population using one case study. However, multiple case study contains two or more cases under the point of interest can give you a replicated result. When the findings remain true for several cases under this research method, your case study’s results become more reliable.

Should you look into all possible explanations for a medical condition?

You should look into all of the possible explanations for the medical condition at hand. If a plight can be explained by more than one reason , then you have to look into the less obvious but similarly compelling explanations. Make your case study as informative as possible.

Is a clinical interaction report valid for generalization?

Since it documents stand-out clinical interactions where a single person or a few number of people are a party of, the findings may not be valid for generalization for a wider population.

What is a case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood ...

What are the factors that affect case conceptualization?

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, ...

What is the process of adapting to a culture different from one's initial culture?

Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

What is the theoretical model of counseling?

The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling . We will use a biopsychosocial model in this article because it is the most common model used by mental health providers.

What are the social factors that affect clinical presentation?

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations.

What is the prognosis of a counselor?

Prognosis. Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.

What are some examples of risk factors?

Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

What is the cross sectional view of a case?

Thecross-sectional view of the case formulation includes observations of thepredominant cognitions, emotions, behaviors (and physiological reactions ifrelevant) that the patient demonstrates in the “here and now” (or demonstratedprior to making substantive gains in therapy). Typically the cross-sectional viewfocuses more on the surface cognitions (ie., automatic thoughts) that areidentified earlier in therapy than underlying schemas, core beliefs, orassumptions that are the centerpiece of thelongitudinal view described below.

What are some examples of precipitating events?

A typical example is a depressive episode precipitated bymultiple events, including failure to be promoted at work, death of a closefriend, and marital strain. In some cases (eg., bipolar disorder, recurrentdepression with strong biological features) there may be no clear psychosocialprecipitant. If no psychosocial precipitants can be identified, note any otherfeatures of the patient’s history that may help explain the onset of illness.

Why do you need to write a case report?

You may need to write a case report as part of a class, your job’s paperwork requirements, for billing purposes, to comply with professional providers, or other reasons. The information in this post will serve as a simple template for organizing your case information and ensuring that all relevant details are present in your summary.

Who secured release of information for Sarah's psychiatrist and primary care physician?

Therapist secured releases of information for Sarah's psychiatrist and primary care physician, and also completed a basic genogram covering three generations of Sarah's family.

Is Sarah's husband in concurrent couples therapy?

She and her husband are in concurrent couples therapy and have negotiated setting boundaries with their daughter. This has relieved the tension between them. Sarah’s presenting problem continues to be her immediate family conflict; however, she has also explained that her family of origin history is relevant to her symptoms of depression.