Ethnic Groups in the Philippines
PSYCHOLOGICAL EVALUATION
(FACILITY NAME HERE)
Jane Smith Dates of Evaluation: 9/12/96
Case No.: 111,111 9/13/96
Building No.: 11
Admission Date: 9/2/96 Date of Report: 9/14/96
PURPOSE FOR EVALUATION: Rather than "Reason for Referral" the first section for the report is better called "PURPOSE FOR EVALUATION." This gives you a lot more flexibility. If you use "Reason for Referral", you pretty much have to copy whatever the consult says. Unfortunately, many consults ask questions which tests can't answer (or else they don't ask any question at all).
Use this section to briefly introduce the patient and the problem. Begin with a concise "demographic picture" of the patient. (e.g., This is the third inpatient admission for this 32 year old, single, white female who has 13 years of formal education and is employed as a beautician. She was admitted due to symptoms of major depression with possible psychotic features.)
Use this section to tell your reader what issues you will address in the body of the report. In this way, he won't get to the end of your report, then have to think back to decide whether your conclusions were supported by your data. He'll know on what issues to focus, and he can be forming his own impressions while he's reading. (e.g., The purpose for the current evaluation was to screen for evidence of psychosis and clarify the nature of the underlying depressive disorder.) In sum, use this section to "pose a question," which you will answer in the "SUMMARY" section.
Finally, if the evaluation takes more than 5 days to complete, you should put a progress note in the patient's chart giving preliminary test results. For example, you might conclude the "PURPOSE FOR EVALUATION" section of your
(FACILITY NAME HERE)
Jane Smith Dates of Evaluation: 9/12/96
Case No.: 111,111 9/13/96
Building No.: 11
Admission Date: 9/2/96 Date of Report: 9/14/96
PURPOSE FOR EVALUATION: Rather than "Reason for Referral" the first section for the report is better called "PURPOSE FOR EVALUATION." This gives you a lot more flexibility. If you use "Reason for Referral", you pretty much have to copy whatever the consult says. Unfortunately, many consults ask questions which tests can't answer (or else they don't ask any question at all).
Use this section to briefly introduce the patient and the problem. Begin with a concise "demographic picture" of the patient. (e.g., This is the third inpatient admission for this 32 year old, single, white female who has 13 years of formal education and is employed as a beautician. She was admitted due to symptoms of major depression with possible psychotic features.)
Use this section to tell your reader what issues you will address in the body of the report. In this way, he won't get to the end of your report, then have to think back to decide whether your conclusions were supported by your data. He'll know on what issues to focus, and he can be forming his own impressions while he's reading. (e.g., The purpose for the current evaluation was to screen for evidence of psychosis and clarify the nature of the underlying depressive disorder.) In sum, use this section to "pose a question," which you will answer in the "SUMMARY" section.
Finally, if the evaluation takes more than 5 days to complete, you should put a progress note in the patient's chart giving preliminary test results. For example, you might conclude the "PURPOSE FOR EVALUATION" section of your