Adult Case Report Format 1

General Guidelines for Write up of Adult Case Report

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General requirements: APA 7 edition should be followed including

● Case report should be written in Times New Romans

● Insert page number at the right top of the page

● Write case report number at the left top of the page by using Header

● Indent each paragraph with line spacing 1.5 with left alignment

● Heading should be followed with the help of APA format.

● Margins are 1.5 inches from the left edge and 1 form the other three edges

● Must number each table and figure separately for each case study

● Give appropriate legend to each table and figure according to the APA

● Give appropriate reference of each technique and assessment tool.

● Give reference in text and in Reference List according to APA 7

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Edition specification

Sequence of Initial Pages

o Title page (Appendix – A)

o Table of Content

o Declaration (Appendix – B)

o Case report completion certificate (Appendix – C)

o Acknowledgment
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o Summary of the Cases (Appendix – D): Table form (client’s initials, age, gender, presenting complains, number of sessions, assessment, diagnosis, management, outcome (in percentage)).
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Adult Case Report Format

● Summary of the Case. (complete brief description of the case, presenting complaints, assessment results with diagnosis and management plan with number of session and outcome report in one paragraph)

● Identifying Data.(initials of the client’s name, age, gender, in-patient or out-patient, marital status, education, no. of sessions, date seen and last date seen)

● Source and Reason for referral. (e.g. Source of the referral: informants, client, psychologist)

● Presenting Complaints.(complaints in the clients verbatim along with their complaints duration by the psychologist/informant and by the client)

● Initial Observation. (appearance, posture, speech, eye contact, behavior on initial contact, client’s own perception of the referral, and any other important significant behavior your observed in the session)

Developmental History of the Problem

● Source of information.

● Chronological course of the problem

● What is the problem, when it started, how it maintained and what is the current level of client’s problem. Highlight the events that made the client vulnerable towards the problem.

● The current status of the client’s problem

Background information

● Personal history (client’s current routine, daily activities, hobbies, likes and dislikes, free time activities, history of accident, head injury, physical injuries, religious inclination)

● Premorbid History (the client’s personal, social and occupational functioning before the illness)

● Family history (family system, number of family members, any significant information, Socio-economic Status, family environment, interaction with family members, genogram, parental education and occupation)

● Sexual history (pubertal changes, reaction toward puberty, sexual relationships, reaction toward those sexual activities)

● Marital history (arrange or love marriage. spouse age, education, occupation, duration of marriage, Relationship with spouse, any conflict reported etc)

● Educational history (schooling started at what age, school performance, interaction with teachers and class fellows).

● Occupational history (Detail of jobs, client view about his job, satisfaction, relationship with colleagues etc)
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● History of family psychiatry / medical illness

● Provisional formulation. Overall conclusion based on the history, including brief summary of risk and protective and maintaining factors of the problem.

● Assessment. List of the assessment modalities, write rationale of each assessment modality and procedure by relating with the clients problem.

o List of Assessment Modalities includes Behavioral observation, clinical interview, Mental Status Examination, subjective ratings of the problem, baseline chart, neuropsychological assessment, projective tests (TAT,

ORT, etc), Self Report Measures.

o Add qualitative and quantitative interpretation of the test scored used for assessment

o Add overall general conclusion of assessment

● Case formulation (summarize all the contributing predisposing, precipitating, maintaining, and protective factors that lead to the current problem, strength and weakness of the client). Provide an understanding and

psychological explanation of the problem. Should include predisposing factors (e.g. genetic predisposing factors), precipitating factors (e.g. parent’s death, conflict in the family, loss of social support), maintaining factors (e.g.

the factors that may not have been involved initially in the development of the problem, but help in maintaining the problems (e.g. poor financial conditions lack of health facilities and family support and client’s personal

motivation), protective factors (the factors that can help the client to cope with the problem e.g. client’s own easy temperament, family bonding)

● Pictorial Description of case formulation (summarize the client’s problem in pictorial manner) (Appendix E)

● Suspected Problem (support your diagnosis with the symptoms and course of problem according to DSM-5)

● Intervention plan (on the basis of assessment results enlist the goals for the management of the clients problem)

● Intervention strategies. Write the rational of each technique by relating with the problem of the client. How it was used with the client, write the process and how client felt and responded.

o Termination of the Therapy (write how the session were terminated with the client)

● Outcome. (Report the comparison with the help of pre and post subjective rating of the client’s problem with the help of table & histogram)

● Limitations.(what are the limitations you have faced in order to deal with the client and achieving short and long term management goals)

● Recommendations (further suggestions that might help the client in future in dealing with the client, follow up)

● Session reports. (session by session report with goals, activities, client’s behavior and outcome)
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● List of references (as per APA 6

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edition format for each case report separately)

● Appendices (copy of referral form, base line charts copies of administered tools , copy of activities carried out in the sessions, copy sample of worksheets, and additional material used in assessment and management)
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Portfolio

Content of Portfolio

1. Weekly Log Book (Appendix – F)

2. Portfolio Cases

3. Group Activities

4. Workshops Attended / Conducted

5. Presentations Attended / Conducted

6. Case Conferences Attended / Given

7. Creative Section

8. Placement Observation with suggestions

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Department of Clinical Psychology

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▪ Title Page (See Appendix for Guidelines)  Yes  No

▪ Case Report Completion Certificate  Yes  No

▪ Declaration  Yes  No

▪ Table of Contents  Yes  No

▪ Font size  Yes  No

▪ Spacing  Yes  No

▪ Margins  Yes  No

▪ Page numbers  Yes  No

▪ Alignment  Yes  No

▪ Reference citation  Yes  No

▪ Tables  Yes  No

▪ Grammar Check (by using software e.g. Ginger)  Yes  No

▪ Quality of Expression  Yes  No

Case Report

1. Summary of the Case  Yes  No

2. Identifying Data  Yes  No

2.1 Initials of name  Yes  No

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2.2 Age  Yes  No

2.3 Gender  Yes  No

2.4 Marital status  Yes  No

2.5 Institute Block  Yes  No

2.6 Date Seen  Yes  No

2.7 Last Date Seen  Yes  No

2.8 No of sessions  Yes  No

3. Reason of referral  Yes  No

4. Presenting Complaints  Yes  No

5. Initial Observation  Yes  No

6. Developmental history of problem  Yes  No

7. Background information  Yes  No

7.1 Personal history  Yes  No

7.2 Premorbid history  Yes  No

7.3 Family history  Yes  No

7.4 Marital history  Yes  No

7.5 Educational history  Yes  No

7.6 Occupational history  Yes  No

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7.7 Medication history  Yes  No

7.8 History of medical/psychiatric illness  Yes  No

8. Provisional formulation  Yes  No

9. Assessment  Yes  No

10. Case formulation  Yes  No

11. Summary of case formulation (table, pictorial)  Yes  No

12. Diagnosis  Yes  No

13. Intervention Plan  Yes  No

14. Implementation of strategies  Yes  No

15. Outcome  Yes  No

16. Pre and post table & histogram  Yes  No

17. Limitations & Recommendations  Yes  No

18. Session reports  Yes  No

19. Reference list  Yes  No

20. Appendices  Yes  No

❖ This document is approved/not approved to be presented to the ________________________ Institute of Clinical Psychology.
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Signature of the Participant/ Candidate _____________________________________

Date __________________

Signature of the Supervisor _____________________________________

Date __________________