If you are a provisional psychologist or a clinical psychology masters student, here is my top tips for writing your case reports.
As a senior psychologist and board approved supervisor I have had the pleasure of reviewing many case reports. Below I have compiled some tips and suggestions for you based on my knowledge of AHPRA and university requirements, and my experience in helping provisional psychologists write pass-worthy case reports.
Follow the relevant checklist. While it seems simple, I have reviewed countless case reports that have not followed the required guidelines. Please start by reviewing the checklist provided by AHPRA or your university. These checklists and guides detail clearly what it is you need to cover and how to structure your case report. There should be separate guides for both the intervention and assessment case reports. When I review and mark case reports, I always refer to this checklist to ensure all components are there.
2. Is it an Assessment or Intervention case report?
Think of your case reports as an opportunity to showcase your emerging skills in psychological assessment and intervention. The type of case report you are writing will require you to focus and demonstrate a particular skill set. Though there is some overlap, please be mindful that if you are writing an Intervention case report, you should have considerably more detail about your intervention plan and delivery than in your Assessment case report (and vice versa).
3. Identifying risk
Ensure that you are clear in your case report that you have conducted a risk assessment, how you went about this, and what the conclusion was. It is important to include the level of risk you designated for this client and how you arrived at that level. You also need to discuss what your plans for ongoing management are (even if there is low risk). If you need assistance understanding how to conduct a complex risk assessment, how to designate risk, and associated management plans you can check out my resource below. It can be used as a template also in your clinical work.
4. Selection of assessments/interventions Ensure you are choosing the most evidence-based assessment measures and interventions for the presenting problem. It is important to include the rationale for your chosen instruments and methods that can be supported by science. It is important to consult the literature about the most appropriate psychological assessments as well as what first line treatment is for the presenting problem and age of the client.
5. Provide a Narrative Summary
When discussing the treatment plan and delivery, provide enough information so we know what actually happened. Don't just list a generic account of the interventions, tell us how the client responded to the interventions. What worked? What roadblocks did you and your clients face? Were there any challenges or did things go off course, and why? This is a great way to demonstrate your ability to handle problems as they arise in therapy in an ethical and competent way.
6. Diagnosis and Differential Diagnosis
When providing a diagnosis, it is important that you have provided sound rationale as to how you arrived at this clinical decision. Ensure you detail the relevant DSM criteria as well as how they met the particular criteria. If they didn't meet certain criteria, please ensure you include that.
You will also need to demonstrate your ability to use clinical assessment and judgment for your differential diagnosis. This means that you have considered any potential diagnoses that could possibly account for some of the presenting symptoms, and have utilised clinical judgment to report on why your chosen diagnosis was a better fit. This is an essential skill for all psychologists and really important to include in your case reports.
7. Demonstrate your competency (but be realistic)Â Â AHPRA and your university know you're early in your career, this isn't about only showcasing the good (though i'm sure you are a great psychologist!). They want to see that you are building your skills in assessment, diagnosis, conducting research on evidence- based interventions, creating appropriate formulations, plans, and demonstrating some skill through delivery. This means that you need to be able to critically evaluate and reflect on the services you have provided.
What were the strengths and weaknesses of your assessment or intervention?
What did you learn from this exercise?
On reflection, what were the things you could have done differently?
If/when things didn't go to plan, how did you manage that?
Your case report is as much an opportunity to build critical self-reflection skills as it is about showing clinical skills.
I hope you found that helpful! If you are looking for in-depth guidance to writing pass worthy case reports which includes: - 2.5 hours of video content which can be logged as CPD
- Two case report templates and two example case reports for both Assessment and Intervention
- Training in Initial Assessments
- Training in Mental Status Examinations
- Training in Risk Assessments and Safety Planning
- Training in Case Formulations and Treatment Planning
- A step by step approach to writing both case reports with discussion about what exactly is needed in each section
- Top tips and discussion about common errors I see when I’m reviewing case reports and how to avoid these