Taking the Patient’s History

Each assignment in this course will help you prepare your Final  Paper. For each assignment, you will use the movie character or  historical figure you chose in your Week One journal. Remember, after  submitting this week’s assignment, you will not be allowed to change  your movie character or historical figure.

One of the first steps  in any clinical assessment is to gather a thorough history from the  patient. This history includes, at minimum, the patient’s identifying  information, presenting problem, and relevant personal history relating  to their presenting problem.

For this assignment, you will write  the first few sections of your psychological report. View the complete  instructions for the Final Paper in the link within Week Five of your  online course or the “Components of Course Evaluation” section of this  guide. This week, your assignment must cover the following sections of  your psychological report and include the headings as listed:

  1. Identifying Information
    Within this section, you  will describe basic information on your patient, including the person’s  name, sex, gender, sexual orientation, age, race, occupation, and  location of residence (country, state, and region).
  2. Chief Complaint/Presenting Problem
    Within this  section, you will include the patient’s primary complaint verbatim to  identify and describe the main source of his or her distress and/or  concerns. If there is no verbatim complaint, include observable  information to create an overall picture of the presenting problem.
    Typically,  this section within a psychological report seeks to answer the  following question (further elaboration within this section is  encouraged where possible):

    • What are the patient’s complaints? (e.g., the patient might complain about “feeling on edge” or experiencing stress)
  3. You will not be completing section III of the Final Paper for this week’s assignment.
  4. Personal History
    Within this section, you will  describe your patient’s personal background and history of abnormal  behavior(s) that inform your diagnostic impression. You will also gather  information about the patient’s cultural background and cultural norms.Typically,  this section within a psychological report seeks to answer the  following questions (further elaboration within this section is  encouraged where possible):

    • Where did the patient grow up?
    • What cultures did the patient experience throughout life?
    • What was the patient’s school life like?
    • What were his or her grades? What is his or her highest level of education?
    • What is the patient’s interpersonal relationship history?
    • What was/is the patient’s romantic relationship history?
    • What was/is the patient’s friendship history?
  5. Family History
    Within this section, you  will describe the patient’s familial relationship(s) and identify any  abnormalities that might affect future treatment. You will also  integrate information about the patient’s family and cultural background  to identify any maladaptive behaviors and relational patterns.Typically,  this section within a psychological report seeks to answer the  following questions (further elaboration within this section is  encouraged where possible):

    • How old were the patient’s parents when the patient was born?
    • Who were the patient’s primary caregivers?
    • What was/is family life like? (Include any information relevant to your diagnostic impression.)
    • Did the family move often?
    • What was/is the patient’s relationship with their siblings (if applicable)?
    • What culture did/does the family come from?
    • What belief systems are attached to that culture?
  6. Therapy History
    Within this section, you will  describe the patient’s therapy history to inform your diagnostic  impression. Analyze the patient’s therapy history to identify the  effectiveness of previous treatment(s). Evaluate previous treatment  interventions based on information and knowledge of the patient’s  cultural background.Typically, this section within a  psychological report seeks to answer the following questions (further  elaboration within this section is encouraged where possible):

    • Who was the previous therapist (if any)?
    • How long did the previous therapy/therapies last?
    • What was the patient’s diagnosis?
    • What interventions did the therapist(s) use?
    • Were those interventions appropriate for the patient’s culture?
    • Was treatment successful?

Your assignment should include both a title page and reference page,  and be of sufficient depth and detail to support and inform your  diagnostic impression, with an absolute minimum of four pages (not  including the title and reference pages). A cursory or surface level  review of the patient’s presenting problem and history will unlikely  provide enough information for your diagnostic impression.

Any sources used in the paper must be cited and referenced in APA style as outlined in the Ashford Writing Center.

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