Case Presentation: Assessment & Diagnosis (CP-AD) Assignment Instructions
Overview
This is the first part of your
Case Presentation
Assignment. This is called a formative assignment in that you will get to “practice” the process of assessment and diagnosis. This is an essential first step toward the development of a sound case conceptualization and treatment plan. It is the foundation of the “golden thread” when working with a client. If you miss the mark here, it can lead your treatment plan astray and potentially do harm.
Instructions
For this
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment,
you will complete the Assessment and Diagnosis portion of the case presentation as illustrated in the
Case Presentation: Assessment and Diagnosis Template and
Case Presentation: Assessment and Diagnosis Example documents.
At the end of this description of instructions, you will see the detailed instructions of the content that CP-AD should have.
You will use the data you collected during the role play (CIR) when you played the role of the counselor during that initial clinical interview. The client you interviewed during the role play (
CIR) will be your client for the entire project of the Case Presentation. The information you gathered during the role play will be used to complete the Case Conceptualization (CC), the Treatment Plan (TP) and the Final Presentation paper
.
As you work on the
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment, you may have to “interview” your client to gain access to missing data points. Additionally, as you work through this
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment, you may “consult” with your clinical team via Microsoft Teams.
Below you will find step-by-step instructions to complete this
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment.
· This assignment is to be 5 to 8 pages in length
· This page count excludes a cover page and reference section
· Please utilize APA 7th edition formatting
· Please be sure to include headings, subheadings and intext citations
· The assignment requires at least 1 citation, e.g., DSM-5-TR (APA, 2022). Do Not use any other version of the DSM, only the DSM-5-TR.
· Note if other sources are used they are to be scholarly articles published within the last five years unless they are considered seminal works in the field of study.
To complete this
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment, do the following:
1) Review the
Case Presentation: Assessment and Diagnosis Instructions below.
2) Review the
Case Presentation: Assessment and Diagnosis Example document.
3) Review the
Case Presentation: Assessment and Diagnosis Template document. Follow the APA formatting as provided in the template. It is developed to help you stay aligned with assignment expectations based on the assignment instructions and grading rubric.
4) Write the Identifying Information and Reason for Referral/Presenting Problem.
5) After collecting all the clinical data, write up the “Summary of Assessment.”
6) After writing the summary, develop your DSM-5 TR diagnosis. Most often in clinical work this will include a primary diagnosis, a comorbidity, and Z-codes. You can “consult” with your clinical team as needed in the development of the diagnosis. Please write the diagnosis in the format indicated in the DSM-5 TR and the example provided.
7) As you begin to establish a diagnosis, consider the definition of Mental Disorder stated in the DSM-5 TR (pp. 13-14) and consider the 4 D’s of diagnosing: deviance, distress, dysfunction, and danger. Consider onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning. Consider differential diagnosis, course of the disorder (partial remission, full remission), and Risk: Suicide, Homicide, and other self-harming behaviors.
8) After you solidified your diagnoses, then develop your diagnostic impression. The impression is an integration of DSM-5 TR criteria, specifiers, severity with supporting evidence from the case study.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool. Make sure the Turnitin report is less than 30%.
Be sure to review the
Case Presentation: Assessment & Diagnosis (CP-AD) Grading Rubric before beginning this
Case Presentation: Assessment & Diagnosis (CP-AD) Assignment.
Please see below the detailed information that needs to be included in the CP-AD. Follow the instructions, template, and example.
Case Presentation: Assessment & Diagnosis (C-PAD) Template
Assessment and Diagnosis
Identifying Data
COUC 667
COUC 667
Page 2 of 2
Date of Initial Assessment:
PSEUDO Name: (this will be the name of the case study client you interviewed in the Role Play; Gretel, Claire, Geore, etc.)
Age:
Gender:
Reason for Referral/Presenting Problem
Provide a brief reason the client has entered into counseling. This may be a triggering event such as a divorce, death, pandemic, loss of employment, bullying or client reported increase in signs, symptoms, impaired functioning, etc. Ideally, offering direct quotes on how the client describes the reason, presenting problem.
Confidentiality
This section should include a statement indicating that you reviewed confidentiality and the limitations therein.
Source of Information
Provide the source and the manner in which data was obtained in the preparation of this report. This includes both formal and informal or semi-structured assessments in the summary as well as throughout the case presentation as necessary to support your conclusions.
Assessment
Offer clinically relevant background information on the client. Write this out in paragraph format using complete sentences, – no bullet points. Note: the case studies are limited and, if no data is present, note this under the heading below. The section should include the following in this order:
(If no assessment data was available, then indicate how would you assess this client in real practice and the importance of assessing such area)
Family and Home Background/Religious Background
Identifying information about parents and siblings (names, ages, occupations, etc.). Client’s perception of the home environment and relationships within the family. Critical family incidents may be included. Also note any events that triggered the client, family coming to counseling, e.g., precipitating events.
Educational History
Description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education. Any assessment information would be helpful.
Mental Health
Historical and as well as present signs, symptoms as well as mental health test results (formal and informal) such as DSM-5 cross-cutting symptom measure, Beck’s Depression Inventory, Beck’s Anxiety Depression Inventory, Patient Health Questionnaire, etc.
Mental Status Exam
When first meeting the client, what are your observations that would include speech; mood; affect; orientation to person, place, time; thought process; delusions; hallucinations; concentration, suicide ideation, etc. Also include any self-harm, e.g, cutting and/or harm to other.
Indicate onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning.
Risk Assessment
A description of the assessment for Suicide, Homicide, and other self-harming behaviors. Indicate the level of risk assessed.
Client’s Physical/Medical Health
A statement of the client’s significant health history, current treatment and medications.
Occupational History
A description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems and reason for change. Quality of work and satisfaction and interests.
Sexual Adjustment
Current status, significant problems or disturbances in functioning, alternate lifestyles
Substance Use History
Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.
Spiritual Assessment
Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness? Additionally, an assessment of the religious background of the family is included.
Cultural Factors
Does the client have any factors such as acculturation, discrimination, etc that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?
Barriers to Treatment/Success
Are there personality factors, stages of change influences, or contextual factors that would influence the success of treatment?
Other pertinent data
Provide any other data points not captured from the sections above such as signs, symptoms, severity, onset, conditions, context that provide a clearer picture for the development and discernment of the diagnosis as well as client insight and motivation to treatment. As you begin to establish a diagnosis, consider the definition of Mental Disorder stated in the DSM-5 TR (pp. 13-14) and consider the 4 D’s of diagnosing: deviance, distress, dysfunction, and danger. Consider onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning. Consider differential diagnosis, course of the disorder (partial remission, full remission), and Risk: Suicide, Homicide, and other self-harming behaviors.
Diagnostic Impressions
DSM-5 Diagnosis
Primary – F 32.1 major depressive disorder, single episode, moderate
Secondary – this may include another diagnosis such as GAD and also Z-codes.
Differential Diagnosis
Be sure to include diagnoses that you are still assessing for to rule them out (For example, you may be ruling out Generalized Anxiety Disorder, but the client has not yet had anxiety for 6 months or longer, so you’re keeping it as a provisional diagnosis). Make sure the rationale is directly connected to the DSM-5 TR.
Diagnosis Rationale
When writing up this section, make sure to offer each disorder criteria with case data to support the diagnosis. For each diagnosis, offer a separate paragraph in the diagnostic impression/rationale. Below are examples of incorrect and correct ways to write it up:
· Not correct– The client has a marked fear about one or more social situations. The individual feared that he will act in a way or show anxiety symptoms that will be negatively evaluated (offered DSM criteria only).
· Not correct – The client is depressed and noted sadness during the interview. The client isolated herself at home (problem, did not connect to DSM criteria).
· Correct – The client has marked fear in several social situations as evidenced by her fear when presenting in class, turning in a paper, and speaking with classmates (A1). She is fearful to speak up when feeling wronged by her supervisor, avoids chatting with co-workers, and isolates herself at home when asked to attend social events (A2). Her fears are founded on the belief that she will act in ways that will be perceived negatively by instructors, classmates, and coworkers (B3). Offer criteria and case study data to support it.
Make sure to use Z codes as needed that are found in the back of the DSM-5 TR. At times, if no disorder is appropriate, a z-code may be the principal diagnosis.
Make sure to offer a paragraph of z-codes in the diagnostic impression/rationale.
The first paragraph is only for the principal diagnosis, the next paragraph is on the second disorder, and then additional paragraphs are for the other disorders. Each paragraph is to focus on only one disorder. It is like building a court defense. If your records are subpoenaed or you transfer a client to another counselor, they are not questioning your diagnosis as being incorrect, or inconclusive based on the diagnostic discussion. For the final paragraph, discuss your differential diagnosis.
This section should include a concise rationale for each diagnosis, differential diagnoses, and Z codes provided above.
References
At least offer the DSM-5 TR as a reference.
