Assessment interview and social histories
Unit 7: Readings
Readings and Resources
Articles, Websites, and Videos:
This chapter focuses on assessment & interview and social histories.
· Writing and human behavior in the social environment . (2018). In Weisman, D., & Zornado, J. L., Professional writing for social work practice, Second Edition (Vol. Second edition). Springer Publishing Company.
This chapter provides an overview of record-keeping relative to legal issues such as court requests with a focus on analytical writing.
· Writing for social work practice . (2018). In Weisman, D., & Zornado, J. L., Professional writing for social work practice, Second Edition (Vol. Second edition). Springer Publishing Company.
Building a Case File
Chapter 9
Chapter Introduction
· Chapter Nine addresses Social Work Case Management Standard 10, Record Keeping, which is focused on building a case file.
· Chapter Nine addresses Human Service–Certified Board Practitioner Competency 4, Case Management, which is focused on building a case file.
I used to work on a federal grant. The files of our clients were really important to us. The information from the files helped us document the work that we did and the outcomes that we had. If I forgot to record an interaction with a client or if I forgot to ask for the client feedback sheet from each visit, then we had a hole in the record. We also used our files to provide better services to our clients. But the pressure from the government made the second reason appear an afterthought.
—Permission granted from Susan Grant (pseudonym), 2014, text from unpublished interview
This chapter examines the types of information that may be found in a case file or that must be gathered to complete one. For each section of the chapter, you should be able to accomplish the following objectives.
The Case File
· Describe the reasons why the case file is important.
Medical Information
· Tell how medical information contributes to a case.
· Decode medical terms.
Psychological Evaluation
· List the reasons for a psychological evaluation.
· Make an appropriate referral.
· Identify the components of a psychological report.
· Review two psychological reports.
· Describe the type of information provided by the DSM-5.
Social History
· State the advantages and limitations of a social history.
· Name the topics included in a social history.
· List the ways social information may appear in the case file.
Other Types of Information
· List the types of educational information that may be gathered.
· Define a vocational evaluation.
· 9-1Introduction
· The case file is filled with information about the client gathered at various times by various professionals. Exactly which information is needed depends on the individual’s case and the agency’s goals, but many cases involve medical, psychological, social, educational, and vocational information. We introduce each type of information, provide a rationale for gathering it, describe the kinds of data likely to be provided, and discuss what the case manager needs to know to make the best use of the report. The following quotations are from individuals who are currently performing the roles of case manager. Reading these quotes will help you hear a first-person front-line perspective of how case managers work with the case files.
· When I am at work it is important for me to remember that I need to know about medical assessments, especially medical terms and how they are used. I use my computer to search terms I don’t know. I also have a hard copy of the Physician’s Desk Reference, although, quite frankly, I primarily use the Internet. I try to have a basic knowledge of special therapies like speech therapy or occupational therapy.
· —Case manager, services for children and families, New York, New York
· Our shelter provides mid-term shelter. A few shelters only provide lodging and services for 4 nights. We allow our clients to remain with us for up to 30 days. Other shelters’ clients have to commit to a year of residence. For our month, we provide clients with a wide range of services. We try to meet all of their needs. Comprehensive assessment is key, and we provide an on-staff psychologist, group counseling, and individual and family work.
· —Director, emergency shelter, St. Louis, Missouri
· When a child is referred to our agency, we immediately seek more information. For example, the first thing a case manager does is contact the school and ask for records. Of course we have a release from the parents to get the records…. We need the school records even if the child is referred for a medical issue.
· —Care manager, high school, Los Angeles, California
· The chapter-opening quotations illustrate the kinds of information that a case manager may need from other professionals to develop a plan or to provide services. The medical information, histories, or exams these three helpers mention are part of the case files of clients who have medical problems. The case manager providing services for children and families speaks of the advantages of being familiar with medical terms and medical references when trying to decipher medical reports. Physical assessments and psychological assessments offer important information to the emergency shelter staff as they work with homeless and runaway female teens. Professional staff at the high school in Los Angeles gather much information about the students from other schools.
9-1aThe Purpose of the Case File
A case file serves a variety of purposes and meets various agency goals. First, the case file provides a summary of the work with the client from eligibility assessment through the end of services and aftercare. This summary is important for an agency to maintain a picture of clients served and the process of case management and outcomes. The record may also be useful for the client if the client needs a record of services to share with other human services agencies. Case files also can provide information useful for evaluating outcomes and assessing possible changes to agency mission, goals, and services. Information in case files help answer accountability questions that agencies must answer. These questions include, “What resources do you have available?”, “How did you spend these resources?”, “What services did you provide?”, and “What were the client outcomes.” At times, difficult issues may arise and the agency or case manager may need the records to address malpractice issues.
Finally, agencies are committed to provide quality care to their clients. Part of that quality of care includes effective responses in times of crises and efficient transition of services as practicing case mangers leave the organization and new staff assume the responsibilities of those leaving. An in-depth case file allows new case managers to establish rapport with and understand their clients and where they are in the case management process.
In summary, the case file directly addresses the critical nature of two facets of case management, that of working with the whole person and that of providing documentation and maintaining good records. This helps in the process of service coordination. Careful attention while building the case file is important for several reasons, including legal accountability, financial and outcome accountability, and effective client services.
The purpose of building a case file shifts during the case management process. For example, when an individual is applying for services, the case manager begins to build a case file to determine if the individual applicant is eligible for services. Once eligibility has been established, the information previously gathered becomes the foundation and provides the initial data for that file. During the case management process, additions are made to the file. These additions may include:
· a)
further assessments;
· b)
the case management plan;
· c)
case manager written case notes;
· d)
periodic assessments of the case management plan and process; and
· e)
revisions of the case management plan.
At the end of the case management process, added to the case file are:
· a)
reasons for ending client services;
· b)
final outcomes;
· c)
plans for client aftercare;
· d)
plans for follow-up;
· e)
client evaluation of services; and
· f)
case manager evaluation of services.
Figure 9.1 illustrates the various aspects of a case file.
Figure 9.1The Case File during the Case Management Process
So, now let us look at one type of information you may find in a case file, that of a medical report or a medical evaluation.
9-1bMedical Evaluation
Knowledge of medical terminology, conditions, treatments, and limitations is important for understanding a case. Medical information may be provided on a form or in a written report. The exam and report may have been completed by a general practitioner or by a specialist in a field such as neurology, orthopedics, or ophthalmology. In some cases, the case manager can interact with the medical service provider and thus will be able to ask questions, request specific assistance, or offer observations. Often, however, he or she does not have this opportunity and must rely on the written report. Then, the resources mentioned at the beginning of the chapter may prove particularly helpful. Many agencies have a copy of the Physician’s Desk Reference (PDR) or other medical guide or may have access to the PDR on a mobile device. Some also have a physician serving as a consultant who is available to answer questions. This section introduces basic medical information to help you understand medical terminology.
Agencies approach medical information in different ways. Some require documentation of a mental or physical disability or condition when determining eligibility for services. Others use a medical examination as part of their assessment procedures. In certain situations, medical information is not gathered unless there is some indication or symptom of a disease, condition, or poor health that would affect service delivery.
Medical knowledge is particularly crucial when working with people who have disabilities. A general medical examination and specialists’ reports help determine the person’s functional limitations and potential for rehabilitation. It is important to set objectives that are realistic in light of the client’s physical, intellectual, and emotional capacities. When a medical report covers a disability in functional terms:
[I]t addresses the following factors [and] the description can read like the following: strength, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, tasting, and smelling, near acuity, far acuity, depth perception, visual accommodation, color vision, and field of vision. (Debates, Rondinelli, & Cook, 2000, p. 81)
Each medical evaluation includes recommendations relating to the individual’s physical, emotional, and intellectual capacities. What follows is a sample medical recommendation.
The individual has a diagnosis of obsessive-compulsive disorder and has limited strength, balancing, hearing, and near-acuity functionality. This person needs work with supervision, few stressors, and limited lifting.
Often, however, the form for a general medical examination allows only a small space for the diagnosis, so the case manager reads a phrase such as “chronic back pain,” “normal exam,” or “emotional problems.” Not very helpful, is it? Remember that the client is an important source of information; he or she can tell you about any problems. You may then need to decide whether or not a specialist’s evaluation would be helpful.
It is important when referring a client for a medical exam that the case manager prepares the client for that experience. This is especially critical from the multicultural perspective. For many individuals, the medical establishment represents a place where they have little knowledge, no power or authority, or have had previous difficult experiences. Many case managers find that the best resource for culturally sensitive physicians is the client himself or herself. When you follow-up on a medical referral, you can ask clients about their experiences.
Voices from the Field
Conducting Culturally Sensitive Medical Exams
An approach to medicine that is client-centered is important. The University of Washington (2009) uses guidelines to educate and train their medical students regarding how to conduct an interview. The guidelines that follow provide case managers with specific ways they may assess the sensitivity of the physicians conducting the medical exam.
Cultural sensitivity in this setting means
· “Appreciating the ethno-cultural, spiritual, and religious perspectives of patients, families, and communities. … The term cultural humility, coined by Tervalon and Murray-Garcia (1998), expands this to include the recognition of power dynamics in health care and the community at large and encourages physician advocacy to address imbalances” (p. 77).
Goals of culturally sensitive medical interviewing and their responsibilities related to each follow.
· Demonstrate contextual sensitivity and use cultural sensitivity. Be aware of family, cultural, and religious values and the influences of gender, age, socioeconomic status, and education level.
· Gather information regarding patient and family perspectives on, and use of, traditional and/or complementary healing strategies.
· Exploring and understanding the approaches patients have used in treating their illness is very important.
· Eliciting this type of information may be challenging. Historically, some patients and family members have been misjudged and even chastised by healthcare professionals for admitting use of alternative or traditional remedies.
· Be cautious and sensitive when trying to elicit this important information.
· Be attentive to any verbal or nonverbal cues that the patient may be uncomfortable discussing alternative healthcare practices (i.e., silence, eye deviation, a shift in their seated position, crossing their arms, etc.).
· Questions such as the following may be helpful to ask:
· Have you seen anyone else about this problem besides a physician?
· Who do you think gives you good health advice?
· Who else do you trust?
· Have you participated in any healing practices or ceremonies to treat your problem?
· Have you used nonmedical remedies or alternative or traditional treatments for your problem?
· What role do they serve in your care?
· Who in your family or community advises you about this condition?
· How common is this condition in your family and/or community?
· What is done commonly to heal this illness?
The University of Washington suggests a model to guide the cultural sensitivity of the physician during the medical exam.
· Beliefs about health (What caused your illness/problem?)
· Explanation (Why did it happen at this time?)
· Learn (Help me to understand your belief/opinion.)
· Impact (How is this illness/problem impacting your life?)
· Empathy (This must be very difficult for you.)
· Feelings (How are you feeling about it?)
9-1cMedical Exams
Generally, medical information contributes to a case in two ways. Medical diagnosis appraises the general health status of the individual and establishes whether a physical or mental impairment is present.
For example, 10-year-old Javier Muldowny comes into state custody, abandoned by his parents. A case manager at the Department of Children’s Services assigns an assessment, care, and coordination team to provide support to Javier. One member of the team takes him to the agency’s health department for an examination. The examination results in a diagnosis of otitis media.
Diagnostic medical services include general medical examinations, psychiatric evaluations, dental examinations, examinations by medical specialists, and laboratory tests. A medical diagnosis is helpful when the client has a medical problem or is currently receiving treatment from a physician who may provide important information about social and psychological aspects of the case in addition to the medical aspects. When making a referral for a medical diagnosis, the case manager should help the client understand why the referral is necessary, the amount of time it will require, what the client can expect to learn, and what use the agency will make of the report.
Medical consultation is used in several ways. First, the consulting physician can provide an interpretation of medical terms and information.
For example, Javier Muldowny was diagnosed with otitis media. The case manager received this report, asked a colleague what the diagnosis meant, and learned that it was an ear infection. A consultation with a physician would reveal that otitis media is a severe ear infection that sometimes results when the eustachian tubes are not properly angled. The consultation might also explain the report further and clarify possible treatments. In Javier’s case, the case manager may need further information about the advantages and disadvantages of two possible treatments: insertion of tubes in the ears or a regimen of antibiotics. A consultation with an otorhinolaryngologist (ear, nose, and throat specialist) could shed light on the medical prognosis and the extent of any hearing disability that might be expected.
The role of a medical consultant is to interpret the available medical data, determine any implications for health and employment, and recommend further medical care if needed. The case manager can make the best use of a consultant by being prepared for the meeting, perhaps specifying in writing what is needed from the consultant. This usually involves identifying problems that need to be resolved and setting forth the significant facts of the case. The case manager needs to understand medical terminology, the skills of specialists in diagnostic study and treatment programs, and the effects of disability on a client.
The medical service used most often in human services is the physical examination , whereby a physician obtains information concerning a client’s medical history and states his or her findings. The exam data are entered into the medical record. Here, we give an overview of the physical examination, including the kinds of information obtained and what the case manager needs to know to make such a referral and to understand the physician’s report.
Diagnosis involves obtaining a complete medical history and conducting a comprehensive physical exam (also called a physical, a health exam, or a medical exam). The results of the exam may be reported on a form provided by the referral source. Sometimes physicians use preprinted schematic drawings of various body parts or organ systems to enhance or clarify the written report. However the information is transmitted, the quality of the reporting depends on the relationship between the physician and the patient. In some cases, the patient may have mixed feelings about the referral for a physical exam. He or she may need an explanation of why the referral is necessary, the amount of time the exam will take, what outcome is expected, and how the information will be used. Keep in mind that the client’s socioeconomic status, language skill limitations, or cultural background may also influence how he or she feels about the referral. If the request is communicated with sensitivity, and if a good relationship with the physician is established, then the client can overcome any barriers of anxiety, depression, fear, or guilt.
The general medical exam is conducted by a physician who takes an overall look at the person’s medical state. Its purpose is to evaluate the person’s current state of health, focusing on two areas. First, a complete medical history records all the factual material, including what the client states and what the physician infers from what is not said. A typical starting point is the chief complaint (symptom), as expressed by the individual. If there is an illness present, then it is described in terms of onset and symptoms (including location, duration, and intensity). A family history relates significant medical events in the lives of relatives, particularly parents, grandparents, siblings, spouse, and children. Extensive information about the individual’s medical history is also collected. This may include childhood diseases, serious adult illnesses, injuries, and surgeries. A review of symptoms focuses on information about present and past disorders, which the physician elicits through questions about organs and body systems. After completing the physical exam, the physician records a diagnostic impression. The actual diagnosis is made once there is conclusive evidence, which may mean performing further studies or referring the client to a specialist for consultation.
Class Discussion
Using Culturally Sensitive Guidelines for Exams and Reports
As an individual, in a group, or as a class, review the Voices from the Field: Conducting Culturally Sensitive Medical Exams. Describe several ways that you might apply the culturally sensitive principles when helping your client prepare for the medical exam. Information you gained in Chapter Six may also help your planning.
Share the results of your discussion with your classmates.
What exactly comprises a medical exam? Techniques used during a physical exam are inspection, palpation (feeling), percussion (sounding out), and auscultation (listening). Usually, the examining physician works from the skin inward to the body, through various orifices, and from the top of the head to the toes (Felton, 1992). Special instruments are used to look, feel, and listen. More time is spent in particular areas to ascertain whether a certain finding truly represents a change in an organ or tissue. Some parts of the exam are performed quickly, and others require more time. More important areas may receive a second, more thorough, examination. The physician records the findings as soon as possible after completing the exam and shares the results with the client.
For some clients, one of the first things occurring in the case management process is a referral to a physician for a general medical exam. This occurred in Sharon’s case, when Tom Chapman referred her. As the physician conducts the exam, he or she completes a form like the one shown in Figure 9.2, which is then sent to the referring counselor. It becomes part of the client record. Figure 9.2 is the form completed by Sharon’s primary care doctor, Dr. Jim Brown.
Figure 9.2
Medical Examination Form
In My Story: Sharon Bello, Entry 9.1, she talks about her experiences with doctors and her reactions after she read the medical report prepared by Dr. Jones that you viewed in Figure 9.2.
Sharon Bello, Entry 9.1
I feel like I have been involved with doctors for such a long time. Between my dad dying, having kids, losing two sons, having my car accident, having two surgeries to try to fix my back after my accident at the senior center, and now needing more medical information to receive rehabilitation services, all of this doctoring and reports, well, it just seems like a lot. For my case management services, if you remember, Tom Chapman asked me to get a letter from Dr. Alderman about my surgery. And I had a long appointment with Dr. Brown for my physical exam. Tom prepared me well for that exam. I knew why I was going and I also knew what to expect.
This is the first time that I have ever read an actual doctor’s report. I contacted Dr. Brown’s office 2 weeks ago to let him know that reading it was important for a project I was involved in. Dr. Brown thought reading the report would be a good idea.
The written report looks different from just participating in the examination and answering questions. I remember, at first, I was afraid that something during the exam would happen and then I would not be able to receive the services. But that didn’t happen. Still, when I read the report, there are a lot of words that I didn’t know and didn’t understand.
What it does look like is that I am fairly healthy. It is just the state of my back that is giving me trouble but, well, that pain when I move is enough for me. Honestly, how my back is, it influences me every day. I guess when the doctor said that I am limited in all ways of moving, he was telling Tom how bad some of my life is for me. And when he said that there was no way to improve my back beyond what has
