Use this outline to structure your case assignments.
1. Case Summary
2. Clinical Impression (Diagnosis)
Write the clinical impression in the DSM-5 format:
XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).
(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)
Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.
Explain any recommendations for interventions, treatment, and/or disposition.
Address the specific questions that were asked in the instructions for this assignment.
Here is a sample assignment question and an appropriate brief response:
Question: Describe what further information you would need to accurately diagnose this case.
Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to…