Diagnosis and Closure

Diagnostic Impression and Conclusions

In the diagnostic impression there are three ways: make a differential diagnosis based on manuals (ICD or DSM), make an impression based on significant features if not all criteria are met, or describe the criteria present without labeling the disorder to soften the result if necessary.

Conclusions should not be confused with a case summary; this section should state the prognosis (positive, guarded), indicate the number of sessions completed, the psychotherapeutic approach used, and the progress or reduction in symptomatology achieved to date.

Recommendations and Final Formalities

Recommendations should be sectorized according to the case: for the patient, for the family and for the institution (school or work) if applicable.

The report should bear the psychologist's signature and stamp on each and every page to avoid alterations or substitutions of pages by third parties.

The ideal length should not exceed three pages to maintain accuracy and avoid filler information that dilutes the clinical profile.

Abstract

The diagnostic impression can be presented as a differential based on manuals, a description of significant features or the detail of criteria present, avoiding rigid labels if they are not completely fulfilled.

The conclusions should not summarize the case, but should establish the prognosis, indicate the number of sessions performed, the therapeutic approach applied and the progress achieved in the reduction of symptomatology.

The recommendations should be sectorized according to the addressee, and the final document should be signed and stamped on each page to avoid alterations, maintaining an ideal maximum length of three pages.