A Call for Action 1. In the middle of the 20th century, we saw our planet from space for the first time. Historians may eventually find that this vision had a greater impact on thought than did the Copernican revolution of the 16th century, which upset the human self-image by revealing that the Earth is not the centre of the universe. From space, we see a small and fragile ball dominated not by human activity and edifice but by a pattern of clouds, oceans, greenery, and soils.
If you use "Reason for Referral", you pretty much have to copy whatever the consult says. Unfortunately, many consults ask questions which tests can't answer or else they don't ask any question at all. Use this section to briefly introduce the patient and the problem. Begin with a concise "demographic picture" of the patient.
She was admitted due to symptoms of major depression with possible psychotic features. Use this section to tell your reader what issues you will address in the body of the report. In this way, he won't get to the end of your report, then have to think back to decide whether your conclusions were supported by your data.
He'll know on what issues to focus, and he can be forming his own impressions while he's reading. Finally, if the evaluation takes more than 5 days to complete, you should put a progress note in the patient's chart giving preliminary test results.
The current report will supplement and elaborate upon those preliminary findings. This also helps communicate to referral sources that you do more than give some tests and copy interpretive statements out of a manual. It lets them know that your evaluation is a professional integration of information from a variety of sources.
Be sure to also note who gave the tests and how long it took. These issues are important if a case ever goes to court. Tests were administered by Jim Smith, M.
In this section present paragraphs dealing with family, social, legal, medical, family mental health, etc. Where possible, provide enough details of prior intervention efforts to clarify what was attempted and whether it was successful. These details will help give the treatment team an idea of what "target level" of adaptive functioning to shoot for in the current intervention.
Let the reader get an idea of how the current admission compares to prior admissions and what specific events precipitated the current admission.
End this section with a brief paragraph summarizing staff observations, patient behavior, level of motivation, etc.
Keep in mind that objective observations by professional staff are one of your best sources of data. Conclude with a sentence indicating medications being taken at the time of testing.
Focus on YOUR observations and impressions. This section of the report should focus on your objective evaluation. Avoid quoting the patient's opinion of his own mood, affect, etc. It's also best to avoid mixing in background information or test information with this section.
A typical MSE for a 'normal' patient might read: Results of mental status examination revealed an alert, attentive individual who showed no evidence of excessive distractibility and tracked conversation well.
The patient was casually dressed and groomed. Orientation was intact for person, time and place. Eye contact was appropriate. There was no abnormality of gait, posture or deportment.
Speech functions were appropriate for rate, volume, prosody, and fluency, with no evidence of paraphasic errors. Vocabulary and grammar skills were suggestive of intellectual functioning within the average range.
The patient's attitude was open and cooperative. His mood was euthymic. Affect was appropriate to verbal content and showed broad range.
Memory functions were grossly intact with respect to immediate and remote recall of events and factual information. His thought process was intact, goal oriented, and well organized. There was no evidence of perceptual disorder.
His level of personal insight appeared to be good, as evidenced by ability to state his current diagnosis and by ability to identify specific stressors with precipitated the current exacerbation.
Social judgment appeared good, as evidenced by appropriate interactions with staff and other patients on the ward and by cooperative efforts to achieve treatment goals required for discharge. There are several "models" for writing test reports. In this model results are focused on possible answers to the referral question s.Sep 02, · How to Write a Legal Brief.
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