PSA6669 - SECTION 5: CLINICAL IMPRESSION
There comes a time in any assessment when the practitioner must formulate an opinion of the individual’s status. The quality of this opinion is directly related to the practitioner’s formal education and professional clinical experience.
The clinical impression is both an ongoing process and declaration of the “state of the individual”. It is a combination of the evaluation of the presenting problem and any other issues that the practitioner discovers during the assessment process.
Typically, the initial clinical impression will be recorded towards the end of a psychosocial assessment form, before the more formal diagnostic impressions – utilizing the DSM codes - and before the disposition, prognosis, and treatment plan. It will incorporate into a concise paragraph some of the most important information that has been recorded on the assessment form in other sections, such as mental status, medical problems, supports and resources, etc.
While a preliminary clinical impression should be noted and recorded in the initial assessment session or sessions, forming a clinical impression is a process that is subject to modification over time as interventions are applied to the problem or as new information about resources or functioning of the individual becomes available. The clinical impression can assist the practitioner in deciding how to focus the psychosocial assessment process.
Problem focused assessments are helpful for individuals who need “fixes” like linkage to specific services, medical interventions or pharmacological management.
Person focused assessments are preferable when life style changes are indicated, or there is a need for symptom management, rehabilitation or personal empowerment.
Psychosocial assessment style and focus is determined by the individual’s needs. Information and referral programs do not usually require “in depth” assessments. These programs usually focus on locating resources for routine services such as child care, heating assistance, medical or dental providers and similar services.
Community practice centers often expect a more comprehensive assessment. These practice centers can be either private or public settings and provide services that range from psychiatric to medical/ surgical interventions, or skilled medical such as home health. They could also be long term care settings such as nursing homes or assisted living facilities.
Because the clinical impression is subject to the practitioner’s personal biases and opinions, it is important to minimize these risks. The practitioner can improve their clinical impression by 1) gathering information from multiple sources, by 2) evaluating the information using several theoretical models, by 3) being aware of and controlling your own cultural biases and by 4) seeking alternative explanations of the data in order to avoid cognitive errors, missed opportunities and only partial identification and resolution of the problem.
It is the practitioner’s responsibility to communicate to the individual that the relevance and effectiveness of the assessment and resulting intervention is directly related to the accuracy and completeness of the information provided. The individual or family being assessed must be empowered to participate, to identify priorities, to develop intervention activities that are relevant and appropriate to a positive outcome.
The practitioner needs to be sensitive not only to what is being disclosed, but also to what is being held back.
The practitioner needs to take note of the individual’s life situation including any psychological, occupational, medical or social skills impairment, any tendency toward violence, substance abuse or life style deficits. [ Kennedy, JA (2003) Kennedy Axis V (K Axis) from www.kenedymd.com] This will include physical appearance, mood and affect, communication strengths, deficits and style, the level of cooperation and functional ability, any legal or financial issues as well as the consistency of the information being provided.
It is the practitioner’s responsibility to evaluate the obvious. This includes the individual’s perception of the problem and how well it relates to the referral information.
It also includes signs or symptoms of psychosis, such as thought disorders, that would indicate the need for a comprehensive psychiatric evaluation. If there is evidence of violence, the practitioner needs to assess the threat of suicidal or homicidal risks and make immediate referrals to protect the individual from self harm or others from being harmed.
The clinical impression needs to take into account the individual’s goals for the assessment and the resulting intervention. It should also identify the antecedent factors and environmental influences that affect the person’s situation as well as the individual’s positive strengths, attributes and competencies.
In addition, the practitioner needs to be aware of the individual’s preferences for style of assessment, gender of the practitioner, and availability for completing the assessment process. Part of your clinical impression needs to account for your ability to comfortably accommodate the individual’s preferences and establish and maintain a strong therapeutic relationship.
If this is not possible then the practitioner needs to discuss referral options with the individual.
Clinical impression is essentially a working diagnosis. It has implications for all aspects of the psychosocial assessment process. The clinical impression is a predictive model for how effective the intervention actions will likely be in helping the individual to achieve their goals. [Harel TZ, Smith DW & Rowles JM (2002) A comparison of psychiatrists’ clinical impression based and social workers computer generated GAF scores. Psychiatric Services, Vol. 53, No. 3, 340-342].
In general, statements of clinical impressions are brief and focused. Samples of clinical impression statements:
“The individual appears to be a reliable informant with sincere commitment to achieving goals by adherence to the developed treatment plan.”
“The individual exhibits moderate difficulty in social and occupational functioning that is compounded by significant medical, financial and legal problems.”
“Some mild psychological problems are evident, but the individual has a strong social support network and financial resources.”
"The individual is an unreliable informant related to substance abuse, severe psychological symptoms, unstable life situation and impaired social skills.”
The clinical impression, as a summary and interpretation of information gathered from all the areas of the psychosocial assessment, should be a statement getting to the heart of what is most important to understand about the client. As noted earlier, in terms of placement within the psychosocial assessment form, it is probably best located towards the end of the assessment form. The clinical impression should obviously be consistent with the information that precedes it detailing what has been discerned concerning the client's psychosocial strengths and challenges.