ࡱ>  #bjbj 4$# ,0#####$&&&&&&$wVJJ##_F##$$#p)ל%D u0,N0JJ : Psychosocial Case Study Format Residents Name: ___________________________ Date of Home Visit: _______________________ Patient Identification For confidentiality, write patients name and hospital or clinic number, address and phone number on the separate contact form provided, which will be kept separate from the case study. Initials or pseudonym which will be used to refer to patient throughout case study report Age Race/Ethnicity Gender Medical History Chief Complaint or major health problem at this time HPI Include current medications at end of HPI Past Medical History Family Medical History Review of Systems Psychosocial History Demographic data (Do not need to repeat identifying information stated above) Marital status and history Sexual history and preference Education Occupational history Socioeconomic status/financial situation Is the current illness creating financial distress? Religious affiliation Place of birth Anything unexpected or unique? Family Genogram and APGAR Genogram Draw a genogram including three generations Include all pertinent information physical/mental illness nature of relationships within family Date of birth Date and cause of death Date of marriage/separation/divorce Occupation APGAR To be completed by patient and family members/significant others Current problems or concerns What are they? How distressing are the problems/concerns? How long has the problems/concerns been occurring? What strategies has the patient used to cope with/solve the problem? What is the incentive for change? Any previous experiences similar to current problem? Background information How does the problem fit in the context of the genogram? If not addressed in the genogram, how does patient relate to others? Include any experiences that have or continue to have an effect on patient (i.e. enriched or impoverished experiences; traumatic events) Current life circumstances How does patient occupy his/her time? Include current psychosocial stressors, coping strategies, and resources Habits eating drinking smoking drugs caffeine Diet Exercise Romantic/sexual attachments Close friends/support group Employment situation Strengths/areas of improvement Process Issues How does patient react to you? How does patient communicate his/her concerns (e.g. openly, honestly, avoids expressing feelings)? What is it like to be in the room with patient? What thoughts/emotions are evoked? Socioeconomic Environment Past education, occupation, religion, economic status, discipline, and housing while growing up Current economic status housing transportation Assessment Problem list from medical and psychosocial history Conclusions Conclusions should be a discussion of your assessment of the psychosocial functioning of patient as well as ways in which it interfaces with his/her organic disease and overall health. If this is not readily derived from the information collected, formulated answers to the following questions will complete this section. What is patients view/model of the world? What behaviors, excess or deficits, or attitudes does patient have that contribute to or alleviate his/her psychosocial and/or medical problem(s)? What factors, genetic or environmental, may have contributed to patients current problem(s)? Plan List some specific suggestions regarding ways in which patient can improve current situation If patient is smoking, specify enroll in a smoking cessation program. Individual/couple/family therapy? Support Group? If nutrition, housing, and/or finances, etc. are problematic, indicate community resources that may be helpful !,01{|M t u ! " ? HI`hi./:"#̼ȼļļļļijļļȯh-LhGA hq5hh45h/eh4h+h45h/eh/e5 h/e5h/e5CJaJh45CJaJh@ h45CJaJ. !NO{|M  6 K b t u ^gd/ep^pgd/e & Fgd4 & Fgd4 & Fgd4gd/e$a$gd4   0 Y C \ ! @ ^@ gd/e & Fgd4 & Fgd4 & Fgd4 & Fgd4 & Fgd4! " ? 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''% % % TTF 8 /@@ LP IK% % % T9G  /@@9 LlMedical History^,8,2N'!2,3TTG " /@@ LP a6!"  % % % TX ^+ /@@ LPa.,% % % TT_ ) /@@_ LP Q% % % T`  + /@@ .LChief Complaint or major health problem at thiC2,!C2N2,22!N,2!2,,22!22,N,2Tp  + /@@  LXs time'N,TT 1 + /@@  LP -!"  % % % TX- d /@@ LPb.2% % % TTe-  /@@e LP K% % % Td- i /@@ LTHPI H9TTj-  /@@j LP -!"  % % % TX\  /@@\ LPi.% % % TT  /@@ LP rK% % % TD h  /@@ )LInclude current medications at end of HPI 3,22,,3!!,2N,2-,22',,222!H9!TTi  /@@i LP -!"  % % % TX ^ /@@m LPc.,% % % TT_  /@@_m LP Q% % % T  /@@m LtPast Medical History8,'Y,2,,H'2"1TT ( /@@m LP -!"  % % % TX d /@@ LPd.2% % % TTe  /@@e LP K% % % T p /@@ LxFamily Medical History7,N0Z,2,,H'2#1TTq  /@@q LP -!"  % % % TX ^j /@@S LPe.,% % % TT_ h /@@_S LP Q% % % T j /@@S LpReview of SystemsC,2,H2!90',N'TT j /@@S LP -!"  TTl  /@@ LP a- % % % Td` P/@@`;L&" WMFC ~TIII.'''% % % TT 8P/@@;LP K% % % T9 P/@@9;LtPsychosocial History<'2,82'2,2N'!2,3TT P/@@;LP 6!"  % % % TXR^/@@LPa.,% % % TT_R/@@_LP Q% % % TP/@@LlDemographic dataH-R22,288,82!2% % % TTR/@@LP TRK/@@<L(Do not need to repeat identifying information stated above)!H2222,,22!,2-,2,2"0312!2!N,22',,2-222,"TTLRx/@@LLP -!"  % % % TX\6/@@\LPi.% % % TT4/@@LP K% % % T 6/@@LMarital status and historyY,!,',2',222'2"1TT  6/@@ LP -!"  % % % T`@8/@@@LTii.% % % TT8/@@LP K% % % T8/@@ LhSexual histor8,32,2'2"T8 /@@Lly and preference/,223!,",",2,-TT 8 /@@ LP -!"  % % % Td%/@@%LTiii.% % % TT/@@LP K% % % Tp/@@ L`Education=22,,22TTq/@@qLP -!"  % % % T`*/@@*xLTiv.2% % % TT/@@xLP K% % % T /@@xLtOccupational historyH,,22,22,2'2#1TT L /@@ xLP -!"  % % % TXF/@@FLPv.2% % % TT/@@LP K% % % T<+ /@@(LSocioeconomic status/financial situation82,2,,222N,',2'!2,2,,'2,22TT, X /@@, LP -!"  % % % TXru/@@r^LP1.2% % % TTs/@@^LP K% % % Tsu/@@^3LIs the current illness creating financial distress? '2,,2!",22,'',!--21!2,2,,2'!,''-TTtu/@@t^LP -!"  % % % T`*w/@@*LTvi.2% % % TTw/@@LP K% % % Tw/@@LxReligious affiliationC,122',!!,23TTw+ /@@LP -!"  % % % Td[/@@DLTvii.2% % % TTY/@@DLP K% % % T[/@@DLhPlace of birth8,,,2!2!3TT#[/@@DLP -!"  % % % Tl]/@@LXviii.2% % % TT]/@@LP K% % % T] /@@LAnything unexpected or unique?H3023122,32,,,22!2222,-TT ]$ /@@ LP -!"  % % % TXjA/@@,LPb.8% % % TTkA/@@k,LP E% % % TA/@@,LlFamily Genogram<3R2M,822,3R&WMFC~TTA/@@,LP TdA/@@,LTand 288Tl A/@@,LXAPGARH=MIITT ) A/@@ ,LP 6!"  % % % TX\C/@@\LPi.% % % TTC/@@LP K% % % T|C/@@L\GenogramH,231!,OTTC/@@LP -!"  % % % TXr'/@@rLP1.2% % % TT%/@@LP K% % % T7 '/@@ LdDraw a genogH!,H,1,231T8 -'/@@8 Lram including three generations",N2,22212!-,1,3,!,22(TT.Z'/@@.LP -!"  % % % TX)/@@LPa.,% % % TT)3/@@LP Q% % % T4)b /@@4"LInclude all pertinent information 3,22,,2-!2,22!2!N,22TTc ) /@@c LP -!"  % % % TX /@@LPi.% % % TT _ /@@ LP K% % % T`  /@@` L|physical/mental illness 230',,N,2,2,''TT 7 /@@ LP -!"  % % % T` /@@iLTii.% % % TT _ ~/@@ iLP K% % % T,` /@@` i%Lnature of relationships within family2,2!,2!",,22'22'H22!,N1TTA/@@iLP -!"  % % % Td /@@LTiii.% % % TT _ /@@ LP K% % % T` ^ /@@`  LhDate of birthH,,2!2!3TT_  /@@_ LP -!"  % % % T` f/@@OLTiv.2% % % TT _ d/@@ OLP K% % % T`  f/@@` OL|Date and cause of deathH,,,22,,2',3!2,,3TT G f/@@ OLP -!"  % % % TXh /@@LPv.2% % % TT h_ /@@ LP K% % % T ` h/@@` #LDate of marriage/separation/divorceH,,2!N-!!-1,(,2,",22222!,-TTh0/@@LP -!"  % % % T` L/@@5LTvi.2% % % TT _ J/@@ 5LP K% % % T` , L/@@` 5 L`OccupationH,,22,23TT- Y L/@@- 5LP -!" % % 666666666666666666666666666666666666 6 66 6  6 66 6  6 66 6  6 66 6  6 66 6 66666666666666666666  d.@Times New Roman--- 82 UcPsychosocial Case Study Format    2 Uc  2 e2c  2 u2c @Times New Roman--- @Times New Roman-@Times New Roman- @Times New Roman-@Times New Roman- @Times New Roman--2 H cResidents 2 cName   2 c: 2 c 42 c___________________________m 2 Gc  2 Hc L2 H+cDate of Home Visit: _______________________     2 :c --- 2 2c @"Arial------2 RcI.--- 2 Zc ---,2 ccPatient Identification 2 c ,c'---2 ~ca.--- 2 c ---y2 IcFor confidentiality, write patients name and hospital or clinic number,    ,c'A2 $caddress and phone number on the sepa >2 X"crate contact form provided, which  ,c'J2 *cwill be kept separate from the case study.   2 cc ,c'@Times New Roman---@"Arial------2 ci.--- 2 c ---w2 HcInitials or pseudonym which will be used to refer to patient throughout    ,c'%2 ccase study report 2 c ,c'---2 cii.e--- 2 c ---2 cAgee 2 c ,c'---2 ciii.--- 2 c --- 2 cRace/Ethnicity 2 c ,c'---2 *civ..--- 2 *c ---2 *cGender 2 *c ,c' 2 8c ---2 FNcII.d--- 2 FZc ---"2 FccMedical History   2 Fc ,c'---2 S~ca.--- 2 Sc ---P2 S.cChief Complaint or major health problem at thi   2 Srcs time  2 Sc ,c'---2 a~cb.--- 2 ac ---2 acHPI  2 ac ,c'---2 oci.--- 2 oc ---I2 o)cInclude current medications at end of HPI   2 o}c ,c'---2 |~cc.--- 2 |c ---)2 |cPast Medical History   2 |c ,c'---2 ~cd.--- 2 c ---,2 cFamily Medical History    2 c ,c'---2 ~ce.--- 2 c ---%2 cReview of Systems  2 c ,c' 2 c ---2 IcIII.--- 2 Zc ---)2 ccPsychosocial History  2 c ,c'---2 ~ca.--- 2 c ---#2 cDemographic data --- 2 c e2 <c(Do not need to repeat identifying information stated above)  2 c ,c'---2 ci.--- 2 c ---22 cMarital status and history  2 .c ,c'---2 cii..--- 2 c ---2  cSexual histor#2 cy and preference 2 Bc ,c'---2 ciii.--- 2 c ---2  cEducation 2 c ,c'---2 civ..--- 2 c ---)2 cOccupational history 2 c ,c'---2 cv.--- 2 c ---G2 (cSocioeconomic status/financial situation  2 uc ,c'---2 c1.--- 2 c ---X2 3cIs the current illness creating financial distress? 2 c ,c'---2 !cvi..--- 2 !c ---+2 !cReligious affiliation 2 !c ,c'---2 /cvii.--- 2 /c --- 2 /cPlace of birth 2 /c ,c'---2 =cviii.e--- 2 =c ---82 =cAnything unexpected or unique? 2 =Pc ,c'---2 K~cb.--- 2 Kc ---"2 KcFamily Genogram   2 Kc 2 Kcand 2 KcAPGARe  2 K1c ,c'---2 Xci.--- 2 Xc ---2 XcGenogram 2 Xc ,c'---2 fc1.--- 2 fc ---2 f cDraw a genog:2 fcram including three generations  2 fc ,c'---2 tca.--- 2 tc --->2 t"cInclude all pertinent information   2 tc ,c'---2 ci.--- 2 c ---/2  cphysical/mental illness   2 c ,c'---2  cii.o--- 2 c ---C2  %cnature of relationships within family  2 c ,c'---2  ciii.--- 2 c ---2   cDate of birth 2 ]c ,c'---2  civ..--- 2 c ---.2  cDate and cause of death  2 c ,c'---2 cv.--- 2 c ---@2  #cDate of marriage/separation/divorce  2 c ,c'---2  cvi..--- 2 c ---2   cOccupation 2 Wc ,c'"System????????--ccccccccccccbbbbbbbbbbbbbbbbaaaaaaaaaa՜.+,0 hp  Emory Healthcare  Title  !"#$%&'()+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fmל%Data 1TableWordDocument4$SummaryInformation(*̶DocumentSummaryInformation8CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q