An initial assessment might include information from interviews, clinical case notes, meetings, telephone calls, observations or daily diaries, past medical history, previous assessments, screening measures conducted during the initial assessment or by other colleagues. Make sure you note previous diagnoses or major treatment (such as inpatient psychiatric hospitalisation). Include placements (e.g. group home or day activity) if relevant for the assessment. Such assessment should form the basis for subsequent action including assessment of outcome. a) Background information on the client Date of birth, age, gender, and handedness. For children and young people with suspected learning age, social and disabilities: family, parents’ educational history, job functioning, marital history, health, siblings age, school performance, family history, medical or developmental history (for children this may include pregnancy, birth, perinatal incidents, hospitalisations-overnight), neurological history (blows to the head, seizures), milestones (first unsupported steps, first words other than mum/dad, toileting), current treatment/medication, school (academic progress reading, writing – and numeracy, socialising with peers, compliance with routines). For adults and older adults: family history, age and cause of deaths, parents’ social and educational history, job functioning, hobbies or interests, marital history, health, siblings age and health status, medical history, neurological history (blows to the head, seizures, stroke etc), current treatment/medication. b) Presenting Complaint Be behavioural and descriptive. How long has there been a problem, how severe is it, when did it start, what is the frequency/duration of the difficulties, does it vary, have there been previous attempts at intervention and how successful were they. c) Clinical impression Observe and comment briefly on grooming and clothes appearance, language and social presentation, affect, response to you, response to testing (is it therefore valid or representative of their actual abilities?). The CPR should contain a clear statement of what the client was like and how much assessment was possible;
An initial assessment might include information from interviews, clinical case notes, meetings, telephone calls, observations or daily diaries, past medical history, previous assessments, screening measures conducted during the initial assessment or by other colleagues. Make sure you note previous diagnoses or major treatment (such as inpatient psychiatric hospitalisation). Include placements (e.g. group home or day activity) if relevant for the assessment. Such assessment should form the basis for subsequent action including assessment of outcome. a) Background information on the client Date of birth, age, gender, and handedness. For children and young people with suspected learning disabilities: family, parents’ age, social and educational history, job functioning, marital history, health, siblings age, school performance, family history, medical or developmental history (for children this may include pregnancy, birth, perinatal incidents, hospitalisations-overnight), neurological history (blows to the head, seizures), milestones (first unsupported steps, first words other than mum/dad, toileting), current treatment/medication, school (academic progress – reading, writing and numeracy, socialising with peers, compliance with routines). For adults and older adults: family history, age and cause of parents’ deaths, social and educational history, job functioning, hobbies or interests, marital history, health, siblings age and health status, medical history, neurological history (blows to the head, seizures, stroke etc), current treatment/medication. b) Presenting Complaint Be behavioural and descriptive. How long has there been a problem, how severe is it, when did it start, what is the frequency/duration of the difficulties, does it vary, have there been previous attempts at intervention and how successful were they. c) Clinical impression Observe and comment briefly on grooming and clothes appearance, language and social presentation, affect, response to you, response to testing (is it therefore valid or representative of their actual abilities?). The CPR should contain a clear statement of what the client was like and how much assessment was possible;
Guidelines_for_the_Submission_of_the_Clinical_Practice_Report_(CPR).docx