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2. Psychiatric Report

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Last amended 
30 July 2015

The format and content of a psychiatric report should, where possible be consistent with the practice guidelines of the RANZCP. Such a report will address the areas listed below. Please note the DVA specific requirements in parts 2.17 to 2.24, below:

 

2.1   The patient's identity

2.2   The referral source and reason for referral

2.3   The location, duration and date/s of interview

2.4   Information sources utilised

2.5   History of the present illness

2.6   Current psychiatric status

2.7   Past psychiatric history

2.8   History of substance use

2.9   Psychosocial/developmental history

2.10 Educational history

2.11 Occupational and military history

2.12 Family psychiatric history

2.13 Forensic/medicolegal history

2.14 General medical history

2.15 Mental status examination

2.16 Supplementary clinical information

2.17 Stressful events: The report should include precise details about any particular events that were experienced, witnessed or learned about by the claimant, before, during or after military service, that could be aetiologically relevant for any diagnosed psychiatric disorders.

2.18 Diagnosis: The report should provide the psychiatric diagnosis or diagnoses, according to the DSM-IV classification and additionally, the psychiatric diagnosis or diagnoses, according to the DSM-5 classification. This is because the RMA is progressively updating its SoPs to take into account the changes associated with DSM-5 progressively, and there is no way for delegates to establish which SoPs will reflect which version of the manual at any time, necessitating the provision of reports under both manuals. For conditions in remission indicate the extent of remission (full or partial) and when that remission occurred. Diagnoses for any non-psychiatric conditions should not be included.

2.19 Date of onset: Specific information about the date/s of onset or permanent worsening of any diagnosed psychiatric condition is needed for investigation purposes. Exact dates should be provided where possible. The date of onset is the date on which the diagnostic criteria for the condition were first fulfilled, not the date on which any symptoms or signs first manifest.

2.20 Causal factors: The report should provide an opinion on the causal or aggravating factors for the diagnosed psychiatric disorder/s, including an opinion on whether there is a possible causal relationship to military service. A causal relationship will be more than a temporal one. One or more of the psychiatric diagnoses of the claimant may be:

  • Related to service;
  • Attributable to an event either before or after service; or
  • Attributable to an event before service, but an event on service aggravated the disorder.

2.21 Treatment: Including current medications and other therapies and whether current treatment is optimal.

2.22 Prognosis: Including the nature of the condition (permanent or temporary, stable or fluctuating) and whether and to what extent the claimant could benefit from further treatment or rehabilitation measures.

2.23 Impairment: Information on the claimant's degree of impairment from psychiatric disorders should be provided by completing the enclosed assessment forms.

2.24 Risk assessment: The report should also highlight any perceived self harm or suicide risk, including an opinion about whether or not DVA assessments or other administrative requirements are likely to heighten or aggravate this perceived risk. If a risk of self harm is identified the claimant's General Practitioner should be notified. A copy of the report should only be sent to the General Practitioner with the claimant's consent, in accordance with section 3, below.