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The Columbia Center's Psychiatric IME results in a report that is objective, comprehensive, and scientifically defensible. The report consists of two main sections, the data section and the opinion section.

I-THE INTRODUCTORY COMPONENT HAS SIX SECTIONS:

• Structure of This Report
• Independent Medical Examination
• Psychiatric Assessment
• Purpose of This Evaluation
• Statement of Non-Confidentiality
• Summary of Opinion

II-THE DATA COMPONENT CONSISTS OF THE FOLLOWING:

REVIEW OF AVAILABLE DOCUMENTS

Includes medical, psychiatric, and psychiatric treatment records, as well as employment and legal records.

HISTORY SECTION

Includes a History of the Present Situation and the Personal, Social, Psychiatric. Medical and Occupational History of the evaluee.

MENTAL STATUS EXAMINATION

A face to face examination of the evaluee, which ascertains the current level of the evaluee's mental functioning, i.e. a systematic documentation of the quality of mental functioning at the time of the interview.

ASSESSMENT SECTION

Specific assessments are made to supplement the psychiatric diagnoses and estimate, respectively, the degree and severity of psychosocial stressors currently acting on the individual and the degree of impairment with respect to overall occupational and social functioning, impulse control, and dangerousness. The assessments also help to establish a trajectory of the evaluee's condition by appraising the overall adaptive functioning of the evaluee, currently and in the past year. These assessments have potential value in assessing the current degree of impairment, and the future prognosis of the evaluee's condition. Another part of the assessment section may be the results of psychiatric tests administered to the examinee either by the Columbia Center or an independent Psychologist.

III-THE OPINION COMPONENT

The report concludes with an opinion section in which the data is organized and interpreted. There are three sub-sections, which are:

• DSM IV Multiaxial Diagnosis of the Evaluee
• Answers to the Client's Specific Referral Questions
  • This section contains the professional opinions reached after reviewing, synthesizing and integrating the information from the data section. The data is transformed into focused, actionable information.
• Discussion of the Pertinent Issues Involved

IV-EXAMINER SECTION

• Examiner Background and Qualifications
• Attestation

THE FINAL REPORT

The information is conveyed in a report to the client and provides a professional, comprehensive psychiatric opinion. This opinion addresses the questions asked by the client in comprehensible terms to help in the process of making legal or administrative decisions concerning the evaluee. This report communicates the information and opinions in a comprehensive understandable manner. It enables the client to engage in informed decision-making regarding the evaluee. The end report is an independent, comprehensive, comprehensible, defensible psychiatric opinion based on objective data and capable of withstanding rigorous scrutiny in an adversarial proceeding in court, if necessary.