Role of assesement and diagnosis in case conceptualization and treatment planning Report

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Case conceptualization is the process of analyzing and putting together patient’s clinical assessment information obtained either through interview, observation or physical assessment in order to come up with hypothesis explaining the patient’s underlying illness (Braun & Cox, 2005).

After identifying the presenting problem physician designs a treatment plan for the patient. A treatment plan involves; setting up of therapy goals, choosing appropriate treatment guiding procedure and planning in terms of therapy time frame and resources required to achieve anticipated prognosis (Kang, Kok & Bateman, 2005).

Clinical assessment and diagnosis have a critical role in case conceptualization. They facilitate efficient identification and assembling of related features during patient review. For instance, incases of multiple illnesses where related signs and symptoms have to be put together and interlinked in order to come up with a diagnosis (Kang, Kok & Bateman, 2005).

To come up with a proper diagnosis a physician has to incorporate and organize clinical assessment data. In addition, he has to critically analyze it and blend it as he converges to the right point. Through assessing a patient, a physician is able to get insight and have a basis for explaining his diagnosis.

Additionally, it puts him in a position to explain how illness has evolved and its devastating impact to the patient (Mead, Hohenshil & Singh, 1997).

Despite formulating diagnosis from clinical assessment, they also forms avenue for determining the expected patient’s prognosis. A physician is able to set therapy time frame and predict on patient’s prognosis. Based on the expected therapy out come and formulated treatment plan, physician can monitor patient’s progress and continuously determine the degree of progress achieved at particular point of therapy process.

Patient’s clinical assessment and diagnosis forms physician guidance frame work. It directs him in formulating therapy interventions, goals and the modalities to be applied in therapy process in addition to strategizing treatment plan.

They also determine the need for patient’s treatment collaboration between different therapy departments. For instance, psychiatric patient may require collaborative treatment interventions from medical doctor, psychiatrist, a counselor or a nurse (Linda, 2004).

Assessment and diagnosis helps physician to clearly adhere and maintain therapeutic relationship with the patient. For instance, during therapy a nurse should adopt nurse patient relationship through out the therapy process contact. This fact ensures that at the end of therapy all stipulated therapy guidelines are adhered to in order to attain anticipated treatment goal (Sierra, 2009).

In addition to understanding therapeutic relationship dynamics, physician maintaing a good relationship with a patient limits chances of facing unexpected difficulties and challenge in the course of therapy process. Finally, assessment and diagnosis plays a vital role in influencing approach technique to any illness not forgetting that they provide a map to guide therapy process (Kang, Kok & Bateman, 2005).

Just like case conceptualization, assessment and diagnosis has importance in treatment planning. Assessment and diagnosis acts as an assurance to the success of treatment plan. They motivate physician to do thorough research in order to come up with appropriate treatment plan. They ensure that physicians are reasonable, responsible and effective in their duties (Sierra, 2009).

They eliminate chances of creating errors either by commission or omission since physician has formulated a right diagnosis and a well structured treatment plan. With assessment and diagnosis, it is easy for physician to track down the patient’s treatment progress.

This fact is aided by the formulated goals, treatment procedures, and the set time frame to achieve better prognosis. To sum up, assessment and diagnosis forms basis for treatment structure and guide in the treatment process for both the physician and patient (Erford, 2010).

Misdiagnosis has repercussions, which includes; being a contributing factor to patient’s death. For instance, if immediate medical interventions are not taken to reverse, alleviate symptoms or stop disease pathogenesis patient may die within short duration.

In psychiatric cases misdiagnosis puts patients at risk of experiencing suicidal attempts (Braun & Cox, 2005). These incidences are common in psychiatric patients suffering from bipolar disorder especially during hypomania, manic or during depressive episodes attacks (Meds cape: consequences of misdiagnosis, 2005).

Wrong diagnosis prolongs patients suffering. Additionaly, it can attract other related problems like family, social, and occupational problems. Incidences of psychiatric patients in depersonalization or de-realization states losing their jobs, having conflicts with family or colleagues and breaking up of their relationships have emerged in the past ( Bufford, 2008).

Medication errors related to wrong diagnosis pose a major threat in terms of patient’s improper treatment, in addition to worsening of patient’s condition.

For example, a patient with bipolar depression should not be administered with antidepressants without mood stabilizer because they can precipitate mania, or hypomania attacks (Forsloff, 2010). Additionally, misdiagnosis can lead to long term or recurrence of illness since patient is not getting the appropriate medical attention (Meds cape: consequences of misdiagnosis, 2005).

To conclude, Case conceptualization is a critical therapeutic tool. It forms a basis for intervention since it helps physician to articulate the information gathered from the patient during physical assessment, interview and observation in order to come up with the right diagnosis (Kang, Kok & Bateman, 2005).

Physicians should adopt a treatment plan comprising of; therapy goals setup, choosing of appropriate treatment guidance procedure, and planning resource and time frame required (Sierra, 2009).

References

Braun, S. A., & Cox, J. A. (2005). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling & Development, 83(4), 425–433.

Bufford, R. K. (2008). Case studies: Escape from Alacatraz [sic]: Finding safety and peace. Journal of Psychology & Christianity, 27(1), 66–72.

Erford, B. (2010). Orientation to the Counseling Profession: Advocacy, Ethics, and Essential Professional Foundations. New York, NY: Springer.

Forsloff, C. (2010). Impact of wrong diagnosis on health care in America. Web.

Kang, S., Kok. P., & Bateman, A. (2005). Case formulation in psychotherapy: Revitalizing its usefulness as a clinical tool. Web.

Linda, S. (2004). Diagnosis and treatment planning in counseling. New York, NY: Springer.

Mead, M. A., Hohenshil, T. H., & Singh, K. (1997). How the DSM system is used by clinical counselors: A national study. Journal of Mental Health Counseling, 19(4), 383–401.

Meds cape: consequences of misdiagnosis. (2005). Web.

Sierra, M. (2009). Depersonalization: A new look at a neglected syndrome. Washington, DC: American Psychological Association.

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