I. Patient Identification
a. For confidentiality, write patient’s 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.
i. Initials or pseudonym which will be used to refer to patient throughout case study report
ii. Age
iii. Race/Ethnicity
iv. Gender
II. Medical History
a. Chief Complaint or major health problem at this time
-Psych Diagnosis per DSM V
b. History of Present Illness
Narrative on how the patient ended up in the unit
c. Past Medical History
d. Family Medical History
e. Review of Systems (Head to Toe Assessment)
III. Psychosocial History
a. Demographic data (Do not need to repeat identifying information stated above)
i. Marital status and history
ii. Sexual history and gender preference
iii. Education
iv. Occupational history
v. Socioeconomic status/financial situation
1. Is the current illness creating financial distress?
vi. Religious affiliation
vii. Place of birth
viii. Anything unexpected or unique?
b. Current problems or concerns
i. What are they?
How distressing are the problems/concerns
i. How long has the problems/concerns been occurring?
ii. What strategies has the patient used to cope with/solve the problem?
iii. What is the incentive for change?
iv. Any previous experiences similar to current problem?
c. Current life circumstances
i. How does patient occupy his/her time?
ii. Include current psychosocial stressors, coping strategies, and resources
iii. Substance use:
1. Binge eating
2. Alcohol use
3. Smoking
4. Drugs or cannabis
5. Caffeine
iv. Diet
v. Exercise
vi. Romantic/sexual attachments
vii. Close friends/support group
viii. Employment situation
ix. Strengths/areas of improvement
d. Process Issues
i. How does patient react to you?
ii. How does patient communicate his/her concerns (e.g. openly, honestly, avoids expressing feelings)?
iii. What is it like to be in the room with patient? What thoughts/emotions are evoked?
e. Socioeconomic Environment
i. Past education, occupation, religion, economic status, discipline, and housing while growing up
ii. Current
1. economic status
2. housing
3. transportation
f. Assessment
i. Problem list from medical and psychosocial history
ii. Conclusions
1. 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.
2. What is patient’s view/model of the world?
3. Suicide Risk and Violence Risk Assessment (SRA/VRA)
SRA (Low, Medium or High Risk)
VRA (Low, Medium or High Risk)
4. What behaviors, excess or deficits or attitudes does patient have that contribute to or alleviate his/her psychosocial and/or medical problem(s)?
5. What factors, genetic or environmental, may have contributed to patient’s current behavioral health problem(s)?
g. Proposed Treatment Plan
i. List some specific treatment plan regarding ways in which patient can improve current situation and prospective discharge plan
1. If patient is using tobacco or vaping specify “enroll in a tobacco or vaping cessation program.”
2. Individual/couple/family therapy?
3. Support Group?
4. If nutrition, housing, and/or finances, etc. are problematic, indicate community resources that may be helpful
5. Intensive Outpatient Program (IOP) referral
5.1 Name Clinic/Facility
5.2 Name of Healthcare Provider
5.3 Time & Place of IOP Appointments
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