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Collaborative Care and Problem Formulation

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Collaborative Care and Problem Formulation


A report, typed line and a half spaced, in Times New Roman.

Word count: 3,000 . Evidence should be supported with reference to background reading and referenced using Harvard System. With your preceptor’s guidance, identify a patient/client who has mental health needs. Please ensure confidentiality of patient and care setting by using pseudonyms. Students please structure the assessment using headings (for Parts 1, 2 and 3).


Introduction (20%)

Date and identifying data– state gender, select the fictitious name for the person and provide date of birth

Context- briefly outline where the person was living and the kind of service that was being provided at the time the report was complied

Sources of information- briefly outline who and what records were consulted, and when and where observations were made in compiling the report

Reason for referral- briefly outline who referred the person to this service and for what reasons

First Person Narrative Account of Problems- how this all began; how this affected me; how I felt at the beginning; how things have changed over time; how this affected my relationships; how do I feel now; what do I think this means; what does a

ll this say about me as a person; what needs to happen now/next?;  what do I expect the nurse to do for me?

Assessment (40%)

History of presenting problems– describe when difficulties or problems first emerged and how these have changed, evolved and have been addressed over time

Personal history– include developmental history- prenatal, early and middle childhood, adolescence and adulthood. Include reference to psychosocial milestones, achievements, relationship and sexual history, vocational and occupational history and current social situation

Family history– describe the family of origin (please use a genogram- and place in your appendix), of key roles within the family and any history of mental health problems and treatment

Substance use history- if applicable- describe specific substances used, under what circumstances, and the quantity, variety, duration and effect of use (tolerance or dependence). Include both illicit drugs and legal substances such as alcohol, tobacco, and caffeine containing products

Current medications– describe all the current medications the person is taking, give the classification of each medication, if therapeutic benefits and possible side effects

Mental Status Examination– conduct and document the time and place of the interview/ observation/ examination and a full mental status assessment (including: appearance, behavior, speech, mood and affect, perceptions, cognition, insight and judgement).

Relevant Examinations– outline the findings from any testing or specialist assessments e.g. neurological examination, psychological and neuropsychological testing, brain imaging (e.g. CT, MRI, PET scans), Electroencephalography (EEG), structured clinical instruments and rating scales, laboratory assessments (serology examinations- toxicology, CBC, blood glucose, kidney and liver function tests, thyroid function tests; blood cultures, HIV, or Hep C screening), Urinalysis ( glucose, protein, drug screening).

Problem Formulation (40%)

Selected Assessment tool– take one or more assessments that might usefully inform the assessment for example, you may choose a specific psychiatric rating scales for example: the Beck Depression Inventory (BDI, BDI-II), or the Abnormal Involuntary Movement Scale (AIMS), Brief Psychiatric Rating Scale (BPRS), Camberwell Family Interview Clinical Global Impression (CGI), Positive and Negative Syndrome Scale (PANSS) or Scale for the Assessment of Negative Symptoms (SANS) or a risk assessment or assessment tool in the clinical area- outline your rationale for your chosen scale. If appropriate provide an outline of results ( The assessment tool must be placed in your appendices).

Medical formulation– outline the DSM-IV or IDC 10 diagnosis for this person

Priorities of care- list four to five Nursing priorities for this person care. Give a brief rationale for each nursing priority which should consider and incorporate a recovery focus.


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