Writing in Psychological Medicine

Written case report

The written case report is an opportunity for students to demonstrate that they have developed a comprehensive formulation and a management plan for a patient that they have personally interviewed.

The case report should record a thorough assessment, demonstrate the student's capacity to appreciate the patient's experience, present an attempt to understand why this patient is ill in this way at this time, and describe what management will be required to facilitate this patient's return to best  possible functioning.

To this end, it is expected that the student will:

  • Present a document which communicates in a clear and orderly fashion
  • Provide appropriately selected historical and examination material, including both positive and negative findings relevant to the case
  • Indicate an awareness of the limitations of the material obtained and presented
  • Demonstrate an awareness of the range of diagnostic issues which need to be considered
  • Present a formulation, drawing together the historical and examination material, so as to develop an understanding of the patient
  • Provide a management plan considering the immediate, short-term, and longer term issues presented by this patient

There is no word limit on the report - the content should be both sufficient and well edited. The judgement on what to include is part of the professional skill under development.

This is a psychological report and therefore the emphasis is on the psychological issues. Note that this does NOT imply the exclusion of medical issues!

Report structure

The information provided in this resource will assist you with structuring information, communicating reasoning, and checking your application of English grammar in the Psychological case report.

The report structure is based on recommendations outlined in the recommended reading for this assignment task: Bloch, S., and B.S. Singh (1991). Foundations of Clinical Psychiatry (2nd Ed.). Melbourne: Melbourne University Press, Chapter 6.

Overview

  1. Case History
  2. 1.1 Introduction
    1.2 History of Presenting Complaint
    1.3 Past Psychiatric History
    1.4 Past Medical History
    1.5 Family History
    1.6 Personal History and Development
  3. Mental State Examination
  4. Physical Examination
  5. Summary and Diagnosis
  6. Formulation
  7. Management