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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:

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).
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)
You will not be completing section III of the Final Paper for this week’s assignment.
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?
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?
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.
Optional: If you would like to start writing additional SECTIONS in your psychological report and submit them along with this assignment for instructor feedback, feel free to cover any sections up to and including Section VIII (Substance Use). Before doing this, please read the Final Paper prompt for guidance on additional sections.

Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment.

Gathering Collateral Information

Each assignment in this course will help you prepare your Final Paper. For all assignments, you will use the movie character or historical figure that you used in your Week Two assignment and selected in your Week One journal.
After gathering your patient?s history, it is considered good practice to contact people who interact with the patient on a regular basis and/or are related to the patient. These people often provide valuable insights into the patient?s behavior(s) and mindset. Typically, the gathered information provides a context for the patient?s environment.
For this assignment, you will write another SECTION of your Final Paper. 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. Your assignment this week must cover the following section of your psychological report and include the heading as listed:
Collateral Within this section, you will interpret specific collateral information as it relates to your patient?s abnormal behavior and behavior patterns. You will also integrate information and knowledge regarding the patient?s culture in your evaluation of the maladaptive behavior as reported by the collateral sources.

Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):
What do other people have to say about the patient?s behavior?
Are there any commonalities between the collateral sources? reports?
Do the collateral sources have any psychological issues that might exacerbate the patient?s problems?
Are there any police reports?
Are there any personality testing or intelligence testing reports available?
Your assignment should be a minimum of one page and include sufficient depth and detail to support and inform your diagnostic impression. A title page is not necessary; however, a reference page must be included. A cursory or surface level investigation of the patient?s interpersonal relationships will not provide enough information for your diagnostic impression. If no collateral information is available, create collateral information on your own to inform your diagnostic impression.
Any sources used in the paper must be cited and referenced in APA style as outlined in the Ashford Writing Center.

Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment.

2/13/17

Final Paper
For your Final Paper, you will demonstrate your knowledge of psychopathology and apply your skills to a realistic scenario. Throughout this course, you have developed unique knowledge and skill sets that will allow you to critically analyze depictions of psychopathology in popular media and historical case examples from an informed point of view.
Your Final Paper will be a psychological report that may be based on a character from a movie or a historical case study. Review the provided lists of movies and historical case studies that are approved for use in this assignment. You must choose from these lists. You may not use examples from your personal life in the psychological report since doing so would be unethical (see Standards 2.04 and 9.01a in the Ethical Principles of Psychologists and Code of Conduct).
As you create this report, you will be taking on the role of a clinician who is conducting an assessment and providing treatment recommendations for a patient (a character from your selected film or historical case study). Please note that a psychological report does not follow the same structure for reports you may have used in other courses. Your report must follow the format below and it must include each of the sections and their headings listed in this order:

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).
Chief Complaint/Presenting Problem

Within this section, you will include the patient?s primary complaint verbatim to identify 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 address 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)
Symptoms

Within this SECTION, you will interpret specific behavioral issues and intrapsychic conflicts as they relate to abnormal behavior, behavior patterns, maladaptive thought processes, and potential unconscious conflicts. Interpret and comment on the patient?s chief complaint and/or presenting problem in the context and language of the symptoms found in the DSM-5. (e.g., the patient who complains about “feeling on edge” might actually be experiencing symptoms related to post-traumatic stress disorder or generalized anxiety disorder)
Personal History

Within this section, you will analyze 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?
Family History

Within this section, you will analyze 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?
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). Analyze 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 applicable)?
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?
Medical Conditions

Within this section, you will analyze the patient?s medical history and comment on any possible medical conditions that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to salient medical conditions. If the person has any medical conditions, indicate that in this section. Integrate information and knowledge about the patient?s cultural background as it affects treatment options for medical conditions.
Substance Use

Within this section, you will analyze and comment on the patient?s substance use to identify any potential issues that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to substance use. If the person misuses specific substances, indicate that in this section. Integrate information and knowledge about the patient?s cultural background to inform your interpretation of substance misuse in this patient?s case.

Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

Which substances does the patient use? (Include any over-the-counter, herbal, and/or prescription medications.)
For how long has the patient used the substance?
What is the patient?s quantity and frequency of use?
Collateral

Within this section, you will interpret specific collateral information as it relates to your patient?s abnormal behavior and behavior patterns. You will also integrate information and knowledge regarding the patient?s culture in your evaluation of the maladaptive behavior as reported by the collateral sources.

Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

What do other people have to say about the patient?s behavior?
Are there any commonalities between the collateral sources? reports?
Do the collateral sources have any psychological issues that might exacerbate the patient?s problems?
Are there any police reports?
Are there any personality testing or intelligence testing reports available?
Results of Evaluation

Within this section, you will analyze the patient?s behavior and mental processes. There are two parts to this section. To begin your analysis, you will write a brief evaluation of each theory of personality development that you learned about in this course and determine whether or not each theoretical orientation can be used to conceptualize the patient?s current situation and treatment goals. Next, use one major theoretical orientation to write an in-depth analysis for your results of evaluation section. Within the context of this theoretical perspective, you will analyze all of the information from the previous sections. Analyze specific behaviors, cognitions, and intrapsychic processes as they relate to your diagnostic impression. Integrate knowledge of the patient?s cultural background and norms within that culture as you prepare your supporting evidence.

Typically, this section within a psychological report seeks to answer the following question (further elaboration within this section is encouraged where possible):

Based on the information you gathered in the previous sections, what led to the patient?s current state?
Diagnostic Impression With Differential Justification

Within this section, you will provide your diagnosis for the patient. To demonstrate your understanding of diagnostic procedure and justification, specifically address each symptom that the patient displayed and relate each symptom to a diagnostic criterion in the DSM-5. Analyze the patient?s behaviors and mental processes within your differential justification. Clearly demonstrate that the patient meets criteria to be given a diagnosis. If the patient does not meet criteria for any diagnosis based on your assessment, explain why. Also, explore any alternative diagnoses and explain why these were not chosen.
Recommendations

Within this section, you will you provide treatment recommendations for the person to help them improve his or her quality of life. These recommendations must be based on the theoretical orientation you used in your Results of Evaluation. Explain why you chose your treatment intervention(s) and include peer-reviewed articles that support your choice(s). If treatment is not necessary, explain why. Pay close attention to the person?s culture since some treatment options may be insensitive to his or her culture or way of living.

Writing the Final Paper

The Final Paper:
Must follow the report outline provided above with the requisite headings and be formatted according to APA style as outlined in the Ashford Writing Center.
Must include a title page with the following:
Title of paper
Student?s name
Course name and number
Instructor?s name
Date submitted
Must address the assessment with critical thought.
Must use at least five peer-reviewed sources that were published within the last ten years, in addition to the text, a minimum of four must be from the Ashford University Library.
Must document all sources in APA style as outlined in the Ashford Writing Center.
Must include a separate reference page that is formatted according to APA style as outlined in the Ashford Writing Center.
Carefully review the Grading Rubrics for the criteria that will be used to evaluate your assignment.

All both assingments and Final paper will be based off fo Earnest Hemmingway

In Ashford courses, there are two different ways to submit assignments for grading. Depending on the system the course utilizes, assignments will either be submitted via the classroom Assignment Basket or Waypoint .

Waypoint Assignment Submission
The assignments in this course will be submitted to Waypoint. Please refer to the instructions below to submit your assignment.
Click on the Assignment Submission button above. The Waypoint “Student Dashboard” will appear.

Browse for your assignment.
Click Upload.
Confirm that your assignment was successfully submitted by viewing the appropriate week’s assignment tab in Waypoint, or clicking on Check Assignment Status within the Meet Your Instructor unit in the left navigation panel.
For more detailed instructions, refer to the Waypoint Tutorial.