Clinical Write Up Example ID: Joseph Smith, 35 years old, male, Caucasian, referred to o/p clinic by wife. CC: Ct was referred to o/p clinic p having an emotional outburst in Walmart p the fire alarm went off while he was next to the broom aisle. Ct states he is, “embarrassed” and “my wife wants me to come in…it has never been this bad before”. HPI: Precipitant was 9/11; ct worked in downtown New York City on the city maintenance team for five years (swept the streets, fixed buildings, painted, ect.). The morning of 9/11 ct was street sweeping on the same block as the Twin Towers. He stated he could, “see the dark black, grey smoke, and hear people screaming. I saw people horrifically injured, dead, and trying to escape. I tried to help.” Pt reports sx: reoccurring and distressing memories of 9/11 (“I can sense everything I can smell the burning, hear the screaming, see the building coming down”), recurrent dreams (1x a week) about the events on 9/11, distress c exposure to external cues that symbolize the trauma (in Walmart when the fire alarm went off the ct happened to be next to the broom aisle, and he grabbed a broom and starting yelling and screaming for people to leave and tried to evacuate the other shoppers), avoidance of external reminders (p 9/11 he quit his job, has no contact with old coworkers, and moved to Alaska. If anything related to NYC appears on television, internet, or in the newspaper he immediately gets upset and turns off the electronic device or closes the paper. Ct reports he constantly feels the, “world is dangerous, especially NYC, so I had to move far away”. He is constantly in a state of fear, and feels like he cannot trust others, so he is very detached from relationships, per ct report. He has switched jobs 12 times since 9/11 because he cannot seem to concentrate on his work, and was showing up to work late due to difficulties falling asleep. Ct notes it usually takes about an hour to three hours on average to fall asleep. Ct reports initially he only had a few sx that were bothersome and initially he could not remember what happened, only little details. However, as time has passed he noticed more and more sx and distressing reactions to remembering the events of 9/11. When asked about SI, ct reports, “no, but I do see darkness from time to time”. SH: Lives c wife (married for 16 years), no children. Ct reports he does not have friends anymore, and he does not like to do much except watch old movies. Ct reports he use to be part of a softball team c his friends, and loved to ride mountain bikes. Currently, he does not play on the team anymore or ride bikes. Ct states he prefers to be alone. Ct works part time at a deli. Ct reports he thinks he is close to his wife still, but if you ask her there is, “distance and misunderstanding between them”. SAHx: Ct denies previous problems c substance abuse and states, “I may have one beer one weekend a month, but I don’t really like the taste”. Ct reports his da.

1. Clinical Write Up Example
ID: Joseph Smith, 35 years old, male, Caucasian, referred to o/p
clinic by wife.
CC: Ct was referred to o/p clinic p having an emotional outburst
in Walmart p the fire alarm went off while he was next to the
broom aisle. Ct states he is, “embarrassed” and “my wife wants
me to come in…it has never been this bad before”.
HPI: Precipitant was 9/11; ct worked in downtown New York
City on the city maintenance team for five years (swept the
streets, fixed buildings, painted, ect.). The morning of 9/11 ct
was street sweeping on the same block as the Twin Towers. He
stated he could, “see the dark black, grey smoke, and hear
people screaming. I saw people horrifically injured, dead, and
trying to escape. I tried to help.” Pt reports sx: reoccurring and
distressing memories of 9/11 (“I can sense everything I can
smell the burning, hear the screaming, see the building coming
down”), recurrent dreams (1x a week) about the events on 9/11,
distress c exposure to external cues that symbolize the trauma
(in Walmart when the fire alarm went off the ct happened to be
next to the broom aisle, and he grabbed a broom and starting
yelling and screaming for people to leave and tried to evacuate
the other shoppers), avoidance of external reminders (p 9/11 he
quit his job, has no contact with old coworkers, and moved to
Alaska. If anything related to NYC appears on television,
internet, or in the newspaper he immediately gets upset and
turns off the electronic device or closes the paper. Ct reports he
constantly feels the, “world is dangerous, especially NYC, so I
had to move far away”. He is constantly in a state of fear, and
feels like he cannot trust others, so he is very detached from
relationships, per ct report. He has switched jobs 12 times since
9/11 because he cannot seem to concentrate on his work, and
was showing up to work late due to difficulties falling asleep.
Ct notes it usually takes about an hour to three hours on average

2. to fall asleep. Ct reports initially he only had a few sx that were
bothersome and initially he could not remember what happened,
only little details. However, as time has passed he noticed more
and more sx and distressing reactions to remembering the events
of 9/11. When asked about SI, ct reports, “no, but I do see
darkness from time to time”.
SH: Lives c wife (married for 16 years), no children. Ct reports
he does not have friends anymore, and he does not like to do
much except watch old movies. Ct reports he use to be part of a
softball team c his friends, and loved to ride mountain bikes.
Currently, he does not play on the team anymore or ride bikes.
Ct states he prefers to be alone. Ct works part time at a deli. Ct
reports he thinks he is close to his wife still, but if you ask her
there is, “distance and misunderstanding between them”.
SAHx: Ct denies previous problems c substance abuse and
states, “I may have one beer one weekend a month, but I don’t
really like the taste”. Ct reports his dad was an alcoholic and
died from liver complications so he, “does not touch the stuff
really”.
PH: Ct denies any previous problems c psychiatric hx.
FH: Ct reports other than his father abusing alcohol he is
unaware of any other mental health issues in his family.
MH: Ct states he is healthy, and not currently taking any rx. He
had a physical exam six months ago. Ct is allergic to trees, dust,
dogs, and cats. Mother is on thyroid medication, per ct report.
MSE: Ct was wearing casual attire (jeans and t-shirt), normally
groomed, and neatly shaven. Very cooperative, but did not make
much eye contact while describing intrusive memories. Ct
speech was NR&V, at times there was rapid speech when
describing traumatic events of 9/11. Ct described his mood as,
“down and embarrassed”. Ct affect was blunt. Ct scored 27 on
the Folestin MMSE. His cognitive fx was A&Ox3. Thoughts
were in normal production range. No bizarre thoughts, per ct
report. Ct content was normal c no production of abnormal
form. Ct offers no evidence of psychosis. Judgment was intact,
and he seemed to recognize that this behavior was not normal

3. and was not reflective of what he use to be like prior to 9/11. Ct
insight is fair. Ct denies suicidal or homicidal ideation.
Assess: Evidence of Posttraumatic Stress d/o precipitated by ct
being involved in the events of 9/11. Ct reports intrusive sx,
persistent avoidance of stimuli, distress, avoidance of stimuli
associated with 9/11 and NYC, and negative cognitions and
mood starting p the exposure to the traumatic event. Ct notes he
has difficulty sleeping and concentrating, and these sx cause
impairment in social and occupational areas of fx. Risk
assessment low, ct denies SI.
Dx:
309.81 Posttraumatic Stress Disorder, c delayed expression
V62.89 Victim of Terrorism
Plan: Ct will be assigned a clinician for o/p therapy as soon as
possible. Ct will also be referred for a medication evaluation
and couples therapy.
The Clinical Write Up
Note: This outline may vary from practice to practice. However,
the content domains included in this sample format are to be
considered ‘industry standard’ for the clinical interview. The
entire write up must be two pages or less. For the purposes of
this class, anything longer than two pages earns no credit. The
clinical write up needs to be in this specific format.
Identifying Data: (ID) Age, gender, ethnicity, other clinically
relevant demographic data, how referred, how arrived, and/or
the setting (outpatient clinic, emergency room, jail, ect). This
part is one to three lines at most. Keep in mind cultural
considerations.
Chief Complaint: (CC) Brief synopsis of reason for presentation
and who is making the complaint. Use a quote from the

4. patient/client; document it in quotation marks, e.g. “I’ve been
so sad lately.” This part is typically one line.
History of Presenting Illness: (HPI) Symptom list,
onset/precipitant (eg. “since learning of her terminal cancer
diagnosis…”), duration, and progression. How it effects his/her
functioning (relationships, home, work, school, friends, usual
activities, etc.) and if it is causing the client distress. Efforts to
compensate (substance use, distraction techniques, and any
coping skills). Include any statements and situational evidence
of risk. This part is probably a quarter to a third of a page.
Include what the patient/client reports or denies.
Social History: (SH) Living situation: marriage, divorced,
widowed, occupation, children, school, military status, ect. This
part is typically one to five lines long.
Substance History: (SAHx) History of all substances of
potential use and abuse. Treatment hx of substance use. Any
recent changes in substance use. This part is typically one to
five lines long.
Psychiatric History: (PH) History of all contact with counselors,
therapists, psychologists, psychiatrists, clinics, ect. If the
client/patient is on any psychiatric medications, list them in this
section. Also include any hospitalizations for mental health.
This part is typically one to five lines long.
Family History: (FH) Family history of mental health issues,
diagnoses, and treatments (include if relatives are on psychiatric
medication). Mental health conditions that run in families. This
part is typically one to three lines long.
Medical History: (MH) History of medical illness, injury, etc.
Include any treatments or current medication the client/patient
is taking. Also note current medical symptoms, side effects of

5. medication, or conditions that effect mental health or behavior.
In this section you can also note any allergies, or illnesses that
run in his or her family. Also include in this section the last
time the client had a physical. This part is typically one to four
lines long.
Mental Status Examination (MSE): THIS is the nuts and bolts of
the psychiatric evaluation. See Mental Status Exam Outline, and
write this section in the order listed on the handout.
Observational evidence of risk is there? This, along with HPI, is
the only other lengthy section. It might be a quarter to a third of
a page long.
Formulation: (Form) or (Assess) WHAT is going on, and WHY
is it going on? What is your clinical assessment of the level of
risk? This part is typically two to five lines long, stating what is
happening, why and the risk.
Diagnosis: (DX) List all diagnoses and any relevant v codes
using the DSM 5.
Plan: What do you recommend? Who will implement this plan?
Level of care? Consider safety, medical condition, cognitive
status, psychotherapy, medications. Do not forgot to rule out
medical. This part is typically two to five lines long.

6. Mental Status Exam Outline
Mental Status:
Appearance
Behavior
Speech (tone, rate, volume)
Mood (subjective)
Affect (objective)

7. Cognitive Fx
(Level of Consciousness, Orientation, Concentration, Memory,
Intelligence, see Folstein Mini-Mental Status Exam).
Perceptions
(Hallucinations, derealization, depersonalization)
Thought Disorder (psychosis)
(Production, Possession, Content, Form)
(Keep in mind: some thought disorders are detected by changes
in the way the patient speaks, which means we should stay
aware for the potential for the possibility of the presence of
problems unique to speech production (i.e. tumors, dementia,
etc.)
**Rule Out Medical** Ask the client/patient when is the last
time they have had a physical or visited their physician.
· Disorders of the Production or Stream of Thought
· In this category there is an alteration in either the amount or
speed of thought.
· Pressure of thought: An increase in the amount of spontaneous
speech compared to what is considered customary. Common in
mania or schizophrenia.
· Poverty of thought: When the client/patient has only a few
thoughts, which lack variety and richness, and seem to move
through the mind slowly. Common in depression or
schizophrenia.
· Thought blocking: A condition where a thought is partially
expressed but not completed.
· Disorders of the Possession of Thought
· Thought insertion: The belief that someone else is inserting
thoughts into my mind.
· Thought withdrawal: The belief that someone else is taking
thoughts from my mind.
· Thought broadcasting: The belief that I can send my thoughts
into the minds of others.
· Disorders of the Content or Meaning of Thought

8. · Delusions: Fixed beliefs that are not based in reality and that
the person refuses to give up, even when presented with factual
information. Can be mood congruent or incongruent.
· Ideas of Reference (referential thinking): The belief that
external communications such as the radio or TV are referring
to me.
· Ideas of Influence: The belief that unrelated actions or events
or conditions are influencing each other (magical thinking, for
example).
· Verbigeration: Sounds, words or phrases are repeated in a
senseless way. It is a type of stereotypy.
· Neologisms: New word formations. e.g. "I got so angry I
picked up a dish and threw it at the gesplinker."
· Echolalia: Echoing of one's or other people's speech
· Disorders of the Form, or Structure of Associations, of
Thought.
· Perseveration: Persistent repetition of words or ideas. (see in
dementia also)
· Derailment: Ideas slip off the track on to another which is
obliquely related or unrelated. The associations are generally
apparent to the listener.
· Concrete Thinking: The client/patient is unable to form
abstract associations. Questions are interpreted in their most
concrete form. “So, what brings you to the office today?” “A
car.”
· Loosening of Associations:
· Circumstantial: Speech that is very delayed at reaching its
goal, citing many unnecessary details along the way. The
associations are generally apparent to the listener.
· Tangential: Speaking in an oblique, tangential or irrelevant
manner, venturing off onto related but unnecessary topics, often
not returning to the original goal. The associations are generally
apparent to the listener.
· Flight of Ideas: Similar to tangential in that there are
numerous changes of topic, yet there is a more rapid and
pressured quality to the switching, and the associations are

9. looser, harder to apprehend for the listener. The initial goal of
the statement is lost.
· Word Salad: Speech that is unintelligible because, though the
individual words are real words, the manner in which they are
strung together results in incoherent gibberish.
Judgment: Can the client/patient make reasonable and safe
decisions.
Insight: Degree of awareness of condition and how it effects his
or her functioning.
Risk: Ideation, Plan, Intent, Access/Feasibility, and Rescue
Factor.
Folstein Mini-Mental Status Exam (maximum score = 30)
ORIENTATION TO TIME (1 pt each)
__ What year is this? __ What season is this? __ What month
is this? __ What is today’s date? __ What day of the week is it?

10. ORIENTATION TO PLACE (1 pt each)
__ Which state are we in? __ Which county are we in? __
Which city are we in? __ Which hospital are we in? __ Which
floor are we on?
IMMEDIATE RECALL (3)
__ Name three objects and ask the patient to repeat all three
objects. Repeat the three objects until the patient learns them
all. Count the number of times it take the patient to learn the
objects.
ATTENTION (either test) (5)
__ Serial 7’s: subtract 7 from 100, then subtract 7 from the
answer you get and keep subtracting 7 until I tell you to stop.
Alternatively, spell the word “world” backwards.
DELAYED RECALL (3) __ What are the three words I
asked you to remember earlier?
NAMING (2) __ Show patient common objects (ie. watch
and pen) and ask the patient to name them.
REPETITION (1) __ Have the patient repeat the following
sentence exactly: “No ifs, ands, or buts.”
3 STAGE COMMAND (3) ___ Have the patient listen first
and then follow these directions when you are finished:
“Take this piece of paper in your right hand, use both hands to
fold it in half, and then put it on the floor.”
READING (1) __ Write this command and tell the patient to
read and follow it: "Close your eyes."
COPYING (1) __ Give the patient a clean sheet of paper and
ask him/her to copy the design
(interlocking pentagons)
WRITING (1) __ On same sheet of paper, ask the patient to
write a complete sentence. The sentence must have acceptable
grammatical structure, with a noun and verb.
**A score of 24 or less indicates increased potential for
cognitive disorder and indicates possible need for more detailed
medical evaluation

11. Common Abbreviations in Clinical Psych Documents
2 due to
means “No change in sleep”
a before
A&Ox3 Alert and Oriented times 3 (person, place, and time)
Assess: Assessment section of the clinical assessment document
c with
CC: Chief Complaint section of the clinical assessment
document
cc chief complaint
Ct client/patient
cx cancel
DFA difficulty falling asleep
dx diagnosis
DX: Diagnosis section of the clinical assessment document
du during

12. EMA early morning awakening
ER emergency room
Form: Formulation section of the clinical assessment
document
FRT faulty referential thinking
fx function
HI homicidal ideation
HPI: History of Presenting Illness section of the clinical
assessment document
hx history
I/P inpatient
ID: Identifying Data section of the clinical assessment
document
LOA loosening of associations
LOC level of consciousness
LTM long term memory
MH: Medical history section of the clinical assessment
document
MMSE: Mini Mental State Exam (Folstein)
ms mental status
MSE: Mental Status Exam
NR& V normal rate and volume
O/P outpatient
p after
PPH: Past Psych History section of the clinical assessment
document
Pt patient
Rx prescribed medication, prescription
s without
SA: Substance Abuse History section of the clinical
assessment document
SCD sleep continuity disturbance
SH: Social History section of the clinical assessment
document
SI suicidal ideation
STM short term memory

13. sx symptom
sx 12 section 12 of Mass State General Law
tx treatment
wnl within normal limits (not we never looked)
Definitions
Disorder: Condition in which there is a disturbance in normal
functioning or reported subjective sense of elevated distress.
Sign: Objective evidence of disease or disorder that can be
observed by evaluator (i.e. bizarre behavior indicative of
psychosis, pacing, fidgeting, ect.).
Symptom: Subjective report of a sign or indication of something
else (i.e. report of chest pain indicating heart attack, or report
of apathy indicating depression), often noted to be a change
from normal function, sensation, or appearance. (this is what
the client/patient reports to the clinician).
Syndrome: A syndrome, by medical definition, is a cluster of
symptoms (made up of signs and symptoms) occurring together,
that characterize a specific disease.
Client for Clinical Interview: Movie Character
Using the format described in Module 4 and the handouts
in the Course Documents Module this semester you will be
completing two clinical write ups. Your Clinical Interview
Write Up assignment has to follow the same format as, “The
Clinical Write Up” document in the Course Documents Module.

14. The assignment needs to a maximum of two pages long, and
have all 12 components that comprise an industry standard
Clinical Interview Write Up that is outlined in the Course
Documents Module. Please refer to the, “Sample Clinical
Interview Write Up” in the Course Documents Module as an
example of the appropriate format.
Clinical
Interview Write will be based on a fictional interview you
complete with a character from a movie. Beyond the clinical
symptom picture that the character presented in the movie, you
can make up the rest of the report to fill out.
Clinical Interview Write Up needs to be from the list below.
Movie
Actor/Actress Character
Black Swan
Natalie Portman
Rain Man
Dustin Hoffman
Silence of the Lambs
Anthony Hopkins
As Good As It Gets
Jack Nicholson
Beautiful Mind
Russell Crowe
Silver Linings Playbook
Bradley Cooper
The Fighter
Christian Bale
Side Effects
Rooney Mara
The Notebook

15. Rachel McAdams
Shutter Island
Leonardo DiCaprio
Mozart and the Whale
Josh Hartnett
Fight Club
Brad Pitt/Edward Norton
Rubric
Clinical Write Up Rubric (1)
Clinical Write Up Rubric (1)
Criteria
Ratings
Pts
Identifying Data Section
1 pts
Chief Complaint Section
1 pts
History of Presenting Illness Section
3 pts
Social History Section
1 pts
Substance History Section
1 pts

16. Psychiatric History Section
1 pts
Family History Section
1 pts
Medical History Section
1 pts
Mental Status Examination Section
3 pts
Formulation/Assessment Section
1.5 pts
Diagnosis Section
3 pts
Plan Section
1.5 pts
Organization of Write Up
1 pts
Total Points: 20