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Case Report Template

The document outlines the structure and requirements for writing a clinical case report, including sections on patient identification, presenting complaints, developmental history, and assessment methods. It emphasizes the need for a concise summary of the case, detailed background information, and a comprehensive management plan. Additionally, it provides guidelines for formatting and referencing within the report.

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24 views6 pages

Case Report Template

The document outlines the structure and requirements for writing a clinical case report, including sections on patient identification, presenting complaints, developmental history, and assessment methods. It emphasizes the need for a concise summary of the case, detailed background information, and a comprehensive management plan. Additionally, it provides guidelines for formatting and referencing within the report.

Uploaded by

sarahhameed4192
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Case Reports

Clinical Internship

Submitted to:

[Supervisor]

Submitted by:

[Student name]

Roll #

BS (Hons) Semester

Session ()

Humanities and Social Sciences Department

GIFT University, Gujranwala


(Clinical Report Writing)

Summary (1st Level)

One Concise Single Paragraph

Summarize the whole case in to a single paragraph through which a reader could
get idea about the case. Name (Initials), age, presenting complaints, brief (history of
present illness, provisional formulation, diagnosis and management plan).

Identifying Data (2nd level)

Name
Father’s Name
Date Of Birth
Assessment Dates
Age
Gender
Examiner
Case No

Reason for Referral

Presenting complaints for which client referred to you

Presenting Complaints

Bullet Points: Include Verbatims

Client’s symptoms, complaints, problems etc. (Write clients verbatim). Sleepiness


(Neend nahi ati).

Developmental History of the Problem/ History of Present Illness

One Paragraph

How problem started, whole picture regarding development of the presenting


problem, current picture of the problem.
Background Information

One Concise Paragraph of each heading

Personal History (3rd level)

Client’s daily activities, hobbies, likes and dislikes, free time activities etc. waking
and sleeping time.

Developmental History

Family History

Start with family system and background, number of family members, any
significant information, father age, occupation, relation with client and any health or
psychological issue as well as for mother, siblings. family environment, interaction with
family members.

Educational History

Schooling started at what age, school performance, interaction with teachers,


and class fellows, favorite subject and games.

Social History

No. of friends, mode and frequency of hang out with friends, clients’ view point
about people around, others view about client, any significant information regarding
socialization of the client

Sexual History

Age of puberty, any complications regarding bodily changes, did you have sex
education at proper age? Wet dreams? Childhood history about sexual harassment.

History of Psychiatry/ Medical Illness

Any personal or family history of psychiatric illness, treatment details,


effectiveness of given treatment. Any personal or family history of chronic/terminal
diseases, treatment, and after effects of illness.
Drug History

If yes then, duration, treatment and specify the drug, onset of age, reason

Assessment

Informal Assessment

(operational definitions of each method of assessment with in-text and out-text


references)

Behavioral Observation. (4th level ) General observation during assessment


sessions), Interaction, communication, style, body language, participation, involvement,
motivation, resistance, behavior, appearance, hygiene, dressing etc.

Clinical Interview. (Briefly mention the information that you obtained from
parents, teachers, or any other informant).

Formal Assessment (Qualitative and Quantitative interpretation of administered tests)

Indigenous Anger Scale. Anger scale was use to measure the severity level of
anger. It was administered because client reported that he was aggressive so that to
check the level of anger it was administered. (Rashid & Siddique 1997). Score and
symptoms only within single range paragraph

Case Formulation

Summarize all the contributing predisposing, precipitating, maintaining and


protective factors that leads to the current problem along with the strengths and
weaknesses of the client. Moreover, provide an understanding and psychological
explanation of the problem. It should include: Predisposing Factors: (Those factors that
renders the child vulnerable to the disorder) Precipitating Factors: (Stressors or
Developmental factors) Perpetuating/Maintaining Factors: (Factors that maintain the
problem) Protective Factors: (Factors that help the client to cope with the problems).
Support your 4P’s with the help of researches.

Diagnosis
According to DSM-V, client falling under the criteria of (code then disorder
name). Example: According to DSM-V client falling/fulfilling under the criteria or might
be fulfilling the symptoms of 319 (F73) Intellectual Disability Disorder, Mild

Client’s prognosis

Describe the factors, which makes prognosis better.

Favourable Point

Unfavourable Point.

Proposed Management plan

Short-term Goals

Long-term Goals

Intervention Strategies

Relaxation Technique

Explain every therapeutic technique within 2-3 line with citation & then
linked/rational all the therapies with you client problem/symptoms

Limitations

Problems that therapist faced while conducting the sessions


References

(In-text)

(Spritzer, 1980) or Spitzer (1980)

(Johnson-Laird, 1978) or Johnson-Laird (1978)

(Out-text)

Spitzer, R. L., Williams, J. B., & Skodol, A. E. (1980). DSM-III: the major achievements
and an overview. The American Journal of Psychiatry

Johnson-Laird, P. N., & Steedman, M. (1978). The psychology of syllogisms. Cognitive


psychology, 10(1), 64-99.

Other Suggestions

 Case report will always be written in past tense, Font style: Times New Roman
and Jameel Noori Nastaleen for Urdu
 all the four areas (left, top, right, bottom) margin should be 1, Line spacing 1.5,
non-justified
 Numbering will be done on the upper right corner, all references should be
mentioned at the last of case reports.

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