Assessment interview and social histories

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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—Permission granted from Susan Grant (pseudonym), 2014, text from unpublished interview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.

My Story

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

How to control medical devices forr ansom

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Assignment : answer real world case 7.1 and 7.2 questions; at least one

Page per case ; cite textbook

Please see chapter readings from textbook below

 

Real World Case 7.1

Remember, databases are used for a variety of reasons and contain large amounts of secondary data. One significant issue that healthcare professionals face is ensuring the data are kept safe and secure. The digitization of healthcare data has created many benefits, but it has also created challenges. A research report from IntSights, “Chronic (Cyber) Pain: Exposed and Misconfigured Databases in the Healthcare Industry,” reveals how hackers are obtaining personally identified information from exposed databases. It is not only old or outdated databases that get breached, some newly established platforms are vulnerable due to misconfiguration or open access. The researchers found that hackers were able to access sensitive data in databases through such simple methods as Google searches (Landi 2018).

Most cybercriminals usually attack for money, but since hospitals don’t hold currency, these attackers target the industry for one of three reasons:

 

1. State-sponsored APTs Targeting Critical Infrastructure: An attempt to infiltrate a network to test tools and techniques to set the stage for larger, future hacks, or to obtain information on a specific individual’s medical condition.

 

2. Attackers Seeking Personal Data: Attackers seek personal data to use in multiple ways such as sell electronic protected health information, blackmail individuals, or use it as a basis for future fraud like phishing or scam calls.

 

3. Attackers Taking Control of Medical Devices for Ransom: Attackers target medial IT equipment to spread malware that exploits specific vulnerabilities and demands a ransom to release the infected devices (Ainhoren 2018).

 

Many healthcare organizations are working diligently to protect themselves from cyber-attacks and threats. It is important to constantly evaluate for gaps in the IT infrastructure and implement strategies such as assessing what needs to be ­secured, mastering identity and mobile device management, testing and re-testing tools, detecting and continuously monitoring threats, and training employees (Davis 2017).

 

While secondary data such as databases makes it a powerful tool for data collection, it is important for healthcare professionals to be aware of the threats and challenges presented which include privacy, security, data quality, and more.

Real World Case Questions 7.1

 

1.         Where can you find information about healthcare database threats?    

· http://www.healthcareitnews.com 

· http://www.ncbi.nlm.nih.gov 

· https://healthitsecurity.com/ 

· https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html 

· https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf 

 

 

2.         Investigate healthcare data breaches for the past year. Identify the main causes of database breaches.

· https://www.healthcareitnews.com/projects/biggest-healthcare-data-breaches-2018-so-far

· https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html

· https://www.hhs.gov/sites/default/files/rtc-breach-20132014.pdf

 

 

 

 

 

 

 

 

 

 

Real World Case 7.2

As mentioned before, many databases are maintained at the state and national level for public use. The National Youth Tobacco Survey (NYTS) serves this purpose and others. The NYTS is used to help provide researchers with information to explore in detail. It also is used as part of a public initiative (Healthy People 2020) for surveillance of trends of adolescent tobacco use (CDC 2019b). Evidence of current topics of secondary data (in other words, databases) is all around us.

A recent report from CDC’s 2018 NYTS indicates that the use of electronic cigarettes (e-cigarettes) is on the rise. The use of e-cigarettes spiked almost 80 percent among high school students and 50 percent among middle school students in the past year. The recent increase is largely due to the popularity of one e-cigarette brand, which looks like a USB flash drive (Boyles 2018).

Vaping, the act of inhaling the vapors of e-­cigarettes, by US teenagers has reached epidemic levels, threatening to hook a new generation of young people on nicotine. “We have never seen use of any substance by America’s young people rise this rapidly,” HHS Secretary Alex Azar ­explains. Vaping is ingrained in the high school culture with kids using e-cigarettes in school bathrooms and even during class. Kids don’t realize many e-cigarettes contain nicotine. Among younger students, candy-flavored e-cigarettes are the most popular, while fruit-flavored products are popular with older students (Finnegan 2018).

Numerous efforts are underway to prevent and reduce tobacco use among young people. The NYTS was designed to provide national data on long-term, intermediate, and short-term indicators to serve as a baseline for data comparison toward meeting the Healthy People 2020 goal of reducing tobacco use among youth (CDC 2018d).

Real world case questions 7.2

1. Research NYTS, covered in real-world case 7.2, and identify the impact that registries have had on consumer and population health. Students can access information on the registry at: https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

 

2.        Investigate activities in your area that are focused on reducing and preventing teen tobacco use. What did you find interesting about the programs? What value does a registry like this provide?

https://msdh.ms.gov/msdhsite/_static/43,0,94,756.html ; https://msdh.ms.gov/msdhsite/_static/resources/7856.pdf

 

 

 

 

HITT 1301 CHAPTER 7

Health Information Management Technology,

An Applied Approach

Nanette Sayles, Leslie Gordon

 

Copyright ©2020 by the American Health Information Management Association. All rights reserved.

Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying,

recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue,

21st Floor, Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint).

 

ISBN: 978-1-58426-720-1

AHIMA Product No.: AB103118

 

 

 

 

As a rich source of data about an individual patient, the health record’s primary purpose is in patient care and reimbursement for individual encounters. (Chapter 3, Health Information Functions, Purpose, and Users, discusses the purpose of the health record in more detail). It is difficult to see trends in a population of patients by looking at individual health records. For this purpose, data must be extracted from individual health records and entered into databases. These data may be used in a facility-specific or population-based registry for research and improvement of patient care (explained later in this chapter). Data may be reported to the state and become part of state- and federal-level databases used to set health policy and improve healthcare. With the electronic health record (EHR), it is possible for data to be collected once in the EHR and used many times (secondary records) for a variety of purposes as outlined in this chapter.

 

The health information management (HIM) professional can play a variety of roles in managing secondary data and databases. The HIM professional plays a key role in database setup. The HIM professional’s role includes determining the content of the database and ensuring compliance with the laws, regulations, and accreditation standards that affect its content and use. All data elements included in the database or registry must be defined in a data dictionary. A data dictionary is a descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database (AHIMA 2014a). For more on the data dictionary, see chapter 6, Data Management. The HIM professional serves as a data steward to oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry. “Data stewardship is a responsibility guided by principles and practices to ensure the knowledgeable and appropriate use of data derived from individuals’ personal health information” (NCVHS 2009, 1). Data stewardship and the role of the data steward are also discussed in chapter 6.

 

This chapter explains the difference between primary and secondary data and its users. It offers an in-depth look at the types of secondary databases, including indexes and registries, and their functions. Finally, this chapter discusses how secondary databases are processed and maintained.

 

Differences between Primary and Secondary Data Sources

The health record is considered a primary data source because it contains information about a patient that has been documented by the professionals who provided care or services to that patient. A primary data source is an original data source where the data are documented or collected by the provider of care. Data derived from the primary health record, such as an index or a database, are considered secondary data sources. These data are known as secondary data.

 

Data are categorized as either patient-identifiable data or aggregate data. With patient-identifiable data, the patient is identified within the data either by name, address, date of birth, or social security number or other government issued identification. The health record consists entirely of patient-identifiable data. In other words, every fact in the health record relates to a particular patient identified by name. Secondary data also may be patient identifiable. In some instances, data are entered into a database along with information such as the patient’s name maintained in an identifiable form. Registries are an example of patient-identifiable data in a secondary data source.

 

Data are patient-identifiable if the identity of the patient is linked via address, age, or another identifier. For example, if an individual can be identified by using a combination of elements such as date of birth, zip code, gender, marital status, and phone number, this would be considered patient-identifiable data.

 

More often, however, secondary data are considered aggregate data. Aggregate data include data on groups of people or patients without identifying any patient individually. Examples of aggregate data are statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis-related group (DRG).

 

Purposes and Users of Secondary Data Sources

There are four major purposes for ­collecting secondary data. They are the following:

1. Quality, performance, and patient safety. Healthcare organizations, for example, collect core measure information from the health record for the Centers for Medicare and Medicaid Services (CMS) to evaluate the quality of care within the healthcare organization.

 

2. Research. Data taken from health records and entered into databases help researchers determine the effectiveness of alternate treatment methods. An example of this type of secondary data use is a disease database that cross-references an index of human diseases, medications, signs, abnormal findings, and more (Diseases Database 2019). Another example is the secondary data collected from the Patient-Centered Outcomes Research Institute (PCORI) used to help patients, ­families, and clinicians make better healthcare choices (PCORI 2019).

 

3. Population health. Population health is an “interdisciplinary, customized approach that allows health departments to connect practice to policy for change to happen locally” (CDC 2019a). For example, states require information be reported to them on certain diseases so the extent of the disease can be determined, and steps taken to prevent the spread of that disease.

 

4. Administrative. In credentialing physicians, healthcare organizations are required to access a national database for information on previous malpractice or other adverse ­decisions against a physician. This information is used to evaluate the qualifications, skills, and performance history of a physician.

 

In healthcare, the health record is a source for various types of data and serves many purposes. The various users of healthcare data are discussed in the following sections.

 

Internal Users

Internal users of secondary data are individuals located within the healthcare organization. For example, internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful to inpatient care, long-range planning, budgeting, and benchmarking with other healthcare organizations.

 

External Users

External users of patient data are individuals and institutions outside the healthcare organization. Examples of external users are state data banks (discussed later in this chapter) and federal agencies. States have laws mandating that cases of patients with diseases such as tuberculosis, sexually transmitted diseases, and other communicable diseases be reported to the state department. The federal government collects data from the states on vital events such as births and deaths.

 

The secondary data provided to external users are generally aggregate data, not patient-identifiable data. Thus, these data can be used as needed without risking breaches of confidentiality.

 

Types of Secondary Data Sources

Secondary data sources consist of ­facility-specific indexes; registries, either facility or population based; or other healthcare databases.

 

Facility-Specific Indexes

The most long-standing secondary data sources are those developed within healthcare organizations to meet their individual needs. These indexes enable health records to be located by diagnosis, procedure, or physician. Prior to extensive computerization in healthcare, these indexes were kept on cards. Today, most indexes are maintained as computerized reports based on data from databases routinely developed in the healthcare organization.

 

Disease and Operation Indexes

The disease index is a listing in diagnosis code number order of patients discharged from the healthcare organization during a specific time period. Each patient’s diagnoses are converted from a verbal description to a numerical code, usually using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The patient’s diagnosis codes are entered into the healthcare organization’s health information system as part of the discharge processing of the patient’s health record. The index always includes the patient’s health record number as well as the diagnosis codes so health records can be retrieved by diagnosis. Because each patient is listed with the health record number, which may be linked to the patient’s name and other information, the disease index is considered patient-identifiable data. The disease index also may include information such as the date of discharge and the attending physician’s name.

 

The operation index is similar to the disease index except that it is arranged in numerical order by the patient’s procedure code(s) using International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) or Current Procedural Terminology (CPT) codes. For specifics on ICD-10-PCS and CPT, refer to chapter 15, Revenue Management and Reimbursement. The other information listed in the operation index is generally the same as that listed in the disease index except that the surgeon may be listed in addition to, or instead of, the attending physician. For ­additional information on coding systems, see chapter 5, Clinical ­Terminologies, Classifications, and Code Systems.

 

Physician Index

The physician index is a listing of cases organized by physician name or physician identification number. It also includes the patient’s health ­record number and may include other information, such as date of discharge. The physician index enables users to retrieve information about a particular physician, including the number of cases seen during a specific time period.

 

Registries

Disease registries are collections of secondary data related to patients with a specific diagnosis, condition, or procedure. Examples of disease registries may include, but are not limited to, Alzheimer’s Prevention Registry, Colon Cancer Family Registry, National and State Cancer Registries, and Rare Disease Registry. Registries are different from indexes because they contain more extensive data. Index reports are usually produced using data from the healthcare organization’s existing databases. Registries often require more extensive entry of data from the health record. Each registry must define the cases that are to be included; this process is called case definition. In a trauma registry, for example, the case definition might be all patients admitted with a diagnosis that includes the ICD-10-CM trauma diagnosis codes.

After the cases to be included have been determined, the next step is usually case finding. Case finding is a method used to identify the patients who have been seen or treated in the healthcare organization for the specific disease or condition of interest to the registry. After cases have been identified, extensive information is abstracted from the patients’ health records into the registry database or extracted from other databases and automatically entered into the registry database.

 

The sole purpose of some registries is to collect data from health records and make them available for users. Other registries take further steps to enter additional information in the registry database, such as routine follow-up of patients at specified intervals. Follow-up information might include rate and duration of survival and quality of life over time. General terminology associated with registries is defined in figure 7.1 and a list of major registries is displayed in table 7.1.

 

Figure 7.1 Terminology associated with registries

Source: ©AHIMA.

 

Table 7.1 Major registries

 

Registry Definition

 

Cancer registry Tracks the incidence (new cases) of cancer

 

Trauma registry Tracks patients with traumatic injuries from the initial trauma treatment to death

 

Birth defects registry Collects information on newborns with birth defects

 

Diabetes registry Collects cases of patients with diabetes to assist in managing care as well as for research

 

Implant registry Tracks the performance of implants including complications, deaths, and defects resulting from implants, as well as implant longevity

 

Transplant registry Maintains databases of cases of patients who need organ transplants

 

Immunization registry Collects information within a particular geographic area on children and their immunization status and maintains a central source of information for a particular child’s immunization history, even when the child has received immunizations from a variety of providers

Source: ©AHIMA.

 

Cancer Registries

According to the National Cancer Registrars ­Association (NCRA), the first hospital cancer registry was founded in 1926 at Yale–New Haven Hospital (NCRA 2018a). It has long been recognized that information is needed to improve the diagnosis and treatment of cancer. Cancer registries were developed as an organized method to collect these data. The data may be facility based (for example, within a hospital or clinic) or population based (for example, from more than one healthcare organization within a state or region).

Facility-based registries include cases from a particular type of healthcare organization such as a hospital or clinic. The data from facility-based registries are used to provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment. The data collected also may provide comparisons in survival rates and quality of life for patients with different treatments and at different stages of cancer at the time of diagnosis. Population-based registries include information from more than one healthcare organization in a specific geographical area such as a state or region. In population-based registries, the emphasis is on identifying trends and changes in the incidence (new cases) of cancer within the area covered by the registry.

The Cancer Registries Amendment Act of 1992 provided funding for a national program of ­cancer registries with population-based registries in each state. According to the law, these registries were mandated to collect data such as the following:

· Demographic data about each case of cancer; demographic data describing the individual, including the patient’s name, age, gender, race, ethnicity, and birthplace

· Information on the industrial or occupational history of the individuals with the cancers (to the extent such information is available from the same health record)

· Administrative information, including date of diagnosis and source of information

· Pathological data characterizing the cancer, including site, stage of the neoplasm (specifies the amount of metastasis, if any), incidence, and type of treatment (Public Law 102-515 1992)

Case Definition and Case Finding in Cancer Registries As defined previously, case definition is the process of deciding which cases should be entered in the registry. For example, in a cancer registry all cancer cases except skin cancer might meet the definition for the cases to be included. Information on malignant neoplasms, data on benign and borderline brain or central nervous system tumors must be collected by the National Program of Cancer Registries (CDC 2018a).

 

In the facility-based cancer registry, the first step is case finding. One way to find cases is through the discharge process in the HIM department. ­During the discharge procedure, coders or discharge analysts can easily earmark cases of patients with cancer for inclusion in the registry. Another case-finding method is using the facility-specific disease indexes to identify patients with diagnoses of cancer. Additional methods may include reviews of pathology reports and lists of patients receiving radiation therapy or other cancer treatments to determine cases that have not been found by other methods.

Population-based registries usually depend on hospitals, physician offices, radiation facilities, ambulatory surgery centers (ASCs), and pathology laboratories to identify and report cases to the central registry. The administrators of a population-­based registry have a responsibility to ensure all cases of cancer have been identified and reported to the central registry.

 

Data Collection for Cancer Registries Data collection methods vary between facility-based and population-based registries. When a case is first entered in the registry, it is assigned an accession number, a number unique to the patient. This number consists of the first digits of the year the patient was first seen at the healthcare organization, and the remaining digits are assigned sequentially throughout the year. For example, the first case in the year might be 21-0001. The 21 indicates that the person was seen in the year 2021. An accession registry is a list of cases in a cancer registry in the order in which they were entered. An accession registry of all cases can be kept manually or provided as a report by the database software. This listing of patients in accession number order provides a way to ensure all the cases have been entered into the registry.

 

In a facility-based registry, data are initially reviewed and collected from the patient’s health record. In addition to demographic information, data in the registry about the patient include the following:

· Type and site of the cancer

· Diagnostic methodologies

· Treatment methodologies

· Stage at the time of diagnosis

 

The stage provides information on the size and extent of spread of the tumor throughout the body. There are currently several staging systems. The American Joint Committee on Cancer (AJCC) has worked through its Collaborative Stage Task Force with other organizations with staging systems to develop a new standardized staging system—the Collaborative Stage Data Set. This staging system uses computer algorithms to describe how far a cancer has spread (Collaborative Stage Data Collection System 2019). After the initial information is collected at the patient’s first encounter, data in the registry are updated periodically through the follow-up process, which is discussed in the section that follows.

 

Frequently, the population-based registry only collects information when the patient is diagnosed. Sometimes, however, it receives follow-up information from its local, state, or national entities. These entities usually submit information to the central registry electronically.

 

Reporting and Follow-up for Cancer Registries Formal reporting of cancer registry data is done annually. The annual report includes aggregate data on the number of cases in the past year by site and type of cancer. It also may include information on patients by gender, age, and ethnic group. Often a particular site or type of cancer is featured with more in-depth data provided.

Other reports are provided as needed. Data from the cancer registry are frequently used in the quality assessment process for a healthcare organization as well as in research. Data on survival rates by site of cancer and methods of treatment, for instance, would be helpful in researching the most effective treatment for a type of cancer.

Another activity of the cancer registry is patient follow-up. On an annual basis, the registry attempts to obtain information about each patient in the registry, including whether they are still alive, status of the cancer, and treatment received during the period. Various methods are used to obtain this information. For a facility-based registry, the healthcare organization’s patient health records may be checked for return hospitalizations or visits for treatment. Additionally, the patient’s physician may be contacted to determine whether the patient is still living and to obtain information about the cancer.

When patient status cannot be determined through these methods, an attempt may be made to contact the patient directly using information in the registry such as the patient’s address and telephone number. In addition, contact information from the patient’s health record may be used to request information from the patient’s relatives. Other methods used include reading newspaper obituaries for deaths and using the Internet to locate patients through sites such as the Social Security Death Index. The information obtained through follow-up is important and allows the registry to develop statistics on survival rates for specific cancers and different treatment methodologies.

Population-based registries do not always include follow-up information on the patients in their databases. However, those who follow up usually receive the information from the reporting entities such as hospitals, physician offices, and other healthcare organizations providing ­follow-up care.

 

Standards and Approval Processes for Cancer Registries Several organizations have developed standards or approval processes for cancer programs. The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program. The ACS standards are published in the Cancer Program Standards (ACS 2019a). When the ACS surveys the cancer program, part of the survey process is a review of cancer registry activities.

The North American Association of Central Cancer Registries (NAACCR) has a certification program for state population-based registries. Certification is based on the quality of data collected and reported by the state registry. NAACCR has developed standards for data quality and ­format and works with other cancer organizations to align their various standards sets.

 

The Centers for Disease Control and Prevention (CDC) also has national standards regarding the completeness, timeliness, and quality of cancer registry data from state registries through the National Program of Cancer Registries (NPCR). The NPCR was developed as a result of the Cancer Registries Amendment Act of 1992. The CDC collects data from the NPCR state registries.

 

Education and Certification for Cancer Registrars Traditionally, cancer registrars have been trained through on-the-job training and professional workshops and seminars. The National Cancer Registrars Association (NCRA) has worked with colleges to develop formal educational programs for cancer registrars. A cancer registrar may become credentialed as a certified tumor registrar (CTR) by passing an examination provided by the National Board for Certification of Registrars (NBCR). Eligibility requirements for the certification examination include a combination of experience and education (NCRA 2018b).

 

Trauma Registries

Trauma registries maintain databases on patients with severe traumatic injuries. A traumatic injury is a wound or other injury caused by an external physical force such as a motor vehicle crash, a gunshot wound, a stabbing, or a fall. Information in the trauma registry may be used for performance improvement and research in the area of trauma care. Trauma registries may be facility based or may include data for a region or state.

 

Case Definition and Case Finding for Trauma ­ Registries The case definition for the trauma registry varies but frequently involves inclusion of cases with diagnoses from the trauma diagnosis codes in the ICD-10-CM. To find cases with trauma diagnoses, the trauma registrar can access the disease indexes looking for cases with codes from this section of ICD-10-CM. In addition, the registrar may look at deaths in services with frequent trauma diagnoses—such as trauma, neurosurgery, orthopedics, and plastic surgery—to find additional cases.

 

Data Collection for Trauma Registries After the cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database. The data elements collected in the abstracting process vary from registry to registry. Abstracting can be either the process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome, or extracting ­elements of data from a source document or database and entering them into an automated system. Data elements in the abstracting process include the following:

 

· Demographic information on the patient

· Information on the injury

· Care the patient received before hospitalization (such as care at another transferring hospital or care from an emergency medical technician who provided care at the scene of the crash or in transport from the crash site to the hospital)

· Status of the patient at the time of admission

· Patient’s course in the hospital

· Diagnosis and procedure codes

· Abbreviated Injury Scale

· Injury Severity Score

 

The Abbreviated Injury Scale (AIS) reflects the nature of the injury and its threat to life by each body system. It may be assigned manually by the registrar or generated as part of the database from data entered by the registrar. The Injury Severity Score (ISS) is an overall severity measurement calculated from the AIS scores for patients with multiple injuries (Agency for Clinical Innovation 2019).

 

Reporting and Follow-up for Trauma Registries Reporting varies among trauma registries. An annual report is often developed to show the activity of the trauma registry. Other reports may be generated as part of the performance improvement process, such as self-extubation (patients removing their own tubes) and delays in abdominal surgery or patient complications. Some hospitals report data to the National Trauma Data Bank (ACS 2019b).

Trauma registries may or may not follow up on the patients entered in the registry. When a follow-up is done, the emphasis is frequently on the patient’s quality of life after a period of time. Unlike cancer, where physician follow-up is crucial to detect recurrence, many traumatic injuries do not require continued patient care over time. Thus, follow-up is often not given the emphasis it receives in cancer registries.

 

Standards and Approval Process for Trauma Registries The ACS certifies levels I, II, III, IV, and V trauma centers. As part of its requirements, the ACS states that the level I trauma center must have a trauma registry (ACS 2019c). As part of its certification requirements, the ACS states that the level I trauma center, the type of center receiving the most serious cases and providing the highest level of trauma service, must have a trauma registry (ACS 2019c). See table 7.2 for a description of each trauma center level.

 

 

 

 

 

 

Table 7.2 Trauma center levels and definitions

 

Trauma center level Description

 

Level I Able to provide total care for every aspect of injury from prevention through rehabilitation

 

Level II Able to initiate definitive care for all injured patients

 

Level III Able to provide prompt assessment, resuscitation, surgery intensive care and stabilization of injured patients, and emergency operations

 

Level IV Able to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher-level trauma center; provides evaluation, stabilization, and diagnostic capabilities for injured patients

 

Level V Able to provide initial evaluation, stabilization, and diagnostic capabilities, and prepares patients for transfer to higher levels of care

Source: ATS 2018.

 

Education and Certification of Trauma Registrars Trauma registrars may be registered health information technicians (RHITs), registered health information administrators (RHIAs), registered nurses (RNs), licensed practical nurses (LPNs), emergency medical technicians (EMTs), or other health professionals. Training for trauma registrars is through workshops and on-the-job training. The American Trauma Society (ATS) provides core and advanced workshops for trauma registrars and a certification examination for trauma registrars who meet its education and experience requirements through its Registrar Certification Board. Certified trauma registrars have earned the certified specialist in trauma registry (CSTR) credential.

 

Birth Defects Registries

Birth defects registries collect information on newborns with birth defects. Often population based, these registries serve a variety of purposes. For example, birth defects registries provide information on the incidence of birth defects to study causes and prevention; monitor trends in birth defects; improve medical care for children with birth defects; and target interventions for preventable birth defects.

 

Case Definition and Case Finding for Birth Defects Registries Birth defects registries use a variety of criteria to determine which cases to include in the registry. Some registries limit cases to those with defects found within the first year of life. Others include those children with a major defect that occurred in the first year of life and was discovered within the first five years of life. Still other registries include only children who were live born or stillborn babies with obvious birth defects.

Cases may be detected in a variety of ways, including review of disease indexes, labor and delivery logs, pathology and autopsy reports, ultrasound reports, and cytogenetic reports. In addition to information from hospitals and physicians, cases may be identified from rehabilitation centers and children’s hospitals and from vital records such as birth, death, and fetal death certificates.

 

Data Collection for Birth Defects Registries A variety of information is abstracted for the birth defects registry, including the following:

· Demographic information

· Codes for diagnoses

· Birth weight

· Status at birth, including live born, stillborn, aborted

· Autopsy

· Cytogenetics results

· Whether the infant was a single birth or one in a multiple birth

· Mother’s use of alcohol, tobacco, or illicit drugs

· Father’s use of drugs and alcohol

· Family history of birth defects

 

Diabetes Registries

Diabetes registries include cases of patients with diabetes for the purpose of assistance in managing care as well as for research. Patients whose diabetes is not kept under control frequently have ­numerous complications. The diabetes registry can keep up with whether the patient has been seen by a physician to prevent complications.

 

Case Definition and Case Finding for Diabetes Registries There are two types of diabetes mellitus: type 1 and type 2 diabetes. Registries sometimes limit their cases by type of diabetes. In some instances, there may be further definition by age. Some diabetes registries, for example, only include children with diabetes.

Case finding includes the review of health records of patients with diabetes. Other case-finding methods include review of the following:

 

· Diagnostic codes

· Billing data

· Medication lists

· Physician identification

· Health plans

Although facility-based registries for cancer and trauma are usually hospital based, facility-based diabetes registries are often found in physician offices or clinics. The office or clinic is the main location for diabetes care. Thus, data about the patient to be entered into the registry are available at these sites rather than at the hospital. The health records of diabetes patients treated in physician practices may be identified through diagnosis code numbers for diabetes, billing data for diabetes-related services, medication lists for ­patients on diabetic medications, or identification of patients as the physician treats them.

Health plans are interested in optimal care for their enrollees because diabetes can have serious complications when not managed correctly. The plans can provide information to the office or ­clinic on enrollees who are diabetics.

 

Data Collection for Diabetes Registries In addition to demographic information about the cases, other data collected may include laboratory values such as glycated hemoglobin, also known as HbA1c. This test is used to determine the patient’s blood glucose for a period of approximately 60 days prior to the time of the test. Moreover, facility registries may track patient visits to follow up with patients who have not been seen in the past year.

 

Reporting and Follow-up for Diabetes Registries A variety of reports can be developed from the diabetes registry. For facility-based registries, one report might keep up with laboratory monitoring of the patient’s diabetes to allow intensive intervention with patients whose diabetes is not well controlled. Another report might concern patients who have not been tested within a year or have not had a primary care provider visit within a year.

Population-based diabetes registries might provide reporting on the incidence of diabetes for the geographic area covered by the registry. Registry data also might be used to investigate risk factors for diabetes.

Follow-up is aimed primarily at ensuring that the patient with diabetes is seen by the physician at appropriate intervals to prevent complications.

 

Implant Registries

An implant is a material or substance inserted into the body, such as breast implants, heart valves, and pacemakers. Implant registries have been developed for the purpose of tracking the performance of implants including complications, deaths, and defects resulting from implants, as well as implant longevity. In the recent past, the safety of implants has been questioned. For example, there have been questions about the safety of silicone breast implants and temporomandibular joint implants. When such cases arise, it has often been difficult to ensure all the patients with the implants have been notified of safety concerns. A number of federal laws have been enacted to regulate medical devices, including implants. These devices were first covered under Section 15 of the Food, Drug, and Cosmetic Act. The Safe Medical Devices Act of 1990 was passed (GPO 1990). It was amended through the Medical Device Amendments of 1992 (GPO 1992). These acts required a sample of healthcare organizations to report deaths and severe complications thought to be due to a device to the manufacturer and the Food and Drug Administration (FDA) through its MedWatch reporting system. The MedWatch reporting system alerts health professionals and the public of safety alerts and medical device recalls (FDA 2018). Implant registries may help ensure compliance with legal reporting requirements for device-related deaths and complications.

 

Case Definition and Case Finding for Implant Registries Implant registries sometimes include all types of implants but often are restricted to a specific type of implant. Examples of specific types of implants may be cochlear, silicone, or temporomandibular joint.

 

Data Collection for Implant Registries Demographic data on patients receiving implants are included in the registry. The FDA requires that all reportable events involving medical devices include the following information: “User facility report number; name and address of the device manufacturer; device brand name and common name; product model, catalog, serial, and lot numbers; brief description of the event reported to the manufacturer or the FDA; where the report was submitted (for example, to the FDA, manufacturer, or distributor)” (FDA 2018).

Thus, these data items should be included in the implant registry to facilitate reporting.

 

Transplant Registries

Transplant registries may have varied purposes. Some organ transplant registries maintain databases of patients who need organs. When an organ becomes available, allocation of the organ to the patient is based on a prioritization method. In other cases, the purpose of the registry is to provide a database of potential donors for transplants using live donors, such as bone marrow transplants. Post-transplant information also is kept on organ recipients and donors.

Because transplant registries are used to try to match donor organs with recipients, they are often national or even international in scope. ­Examples of national registries include the UNet of the United Network for Organ Sharing (UNOS) and the registry of the National Marrow Donor Program (NMDP).

 

Data collected in the transplant registry may be used for research, policy analysis, and quality control.

 

Case Definition and Case Finding for Transplant Registries A physician will identify patients needing transplants. Information about the patient is provided to the registry. When an organ becomes available, the patient’s information is matched with potential donors. For donor registries, donors are solicited through community information efforts similar to those carried out by blood banks to encourage blood donations.

 

Data Collection for Transplant Registries The type of information collected varies according to the type of registry. Pre-transplant data about the recipient include the following:

· Demographic data

· Patient’s diagnosis

· Patient’s status codes regarding medical urgency

· Patient’s functional status

· Whether the patient is on life support

· Previous transplantations

Development of recovery model

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you will prepare a research p to interpret the recovery model. Be sure to include the following:

  • Illustrate the development of the recovery model (historical context, key contributors).
  • Define the recovery model (drawn from the readings and your research).
  • Indicate the major concepts of the recovery model.
  • Interpret how postmodernism and social constructionism are related to the recovery model. How are these concepts included in work with the recovery model?
  • Explore the importance of the recovery model to marriage and family therapy practice.
  • Explain how you believe the application of concepts from the recovery model will make you a more effective MFT.

A resiliency-based approach

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Learning Resources

Required Readings

Toseland, R. W., & Rivas, R. F. (2017). An introduction to group work practice (8th ed.). Pearson.

· Chapter 5, “Leadership and Diversity” (pp. 137–159)

 

Vitrual Book:

Username: etallent9525@aol.com

Password: Landon2019!

 

Rasheed, J. M., Rasheed, M. N., & Marley, J. A. (2010). Ethnicity and family life. In Family therapy: Models and techniques (pp. 83–131). Sage.

 

Credit line: Family therapy: Models and techniques by Rasheed, J.M., Rasheed, M.N., & Marley, J.A. Copyright 2010 by Sage Publications. Reprinted by permission of SAGE Publications via the Copyright Clearance Center. Licensed in 2022.

 

Van Hook, M. P. (2019). Cultural issues, family structure, and resiliency. In Social work practice with families: A resiliency-based approach (3rd ed., pp. 107–151). Oxford University Press.

 

Credit line: Social work practice with families: A resiliency-based approach, 3rd Edition by Van Hook, M.P. Copyright 2019 by Oxford University Press. Reprinted by permission of Oxford University Press via the Copyright Clearance Center. Licensed in 2022.

 

National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

 

Assignment: Culture in Groups

 

Much of the success of a group can be attributed to its composition. Group composition encompasses not only the group’s size and treatment focus but also characteristics of diversity such as gender, age, ability, and race and ethnicity. Imagine a group in which all members are of the same ethnicity except for the social worker. Or a group in which half are recent immigrants with limited language proficiency. Or one in which there is a truly diverse representation of cultures. How would each of these scenarios affect group dynamics and functioning? No matter the situation, a social worker must be poised to approach the group from a stance of cultural competence, humility, and sensitivity.

In this Assignment, you examine the influence of culture on group dynamics and how a social worker can intervene with cultural sensitivity.

To Prepare

· Review the Learning Resources on leadership and diversity within the context of a group setting.

· Reflect on the influence of culture on the dynamics of a group, and how you as a group leader would demonstrate cultural competence and sensitivity.

·

October 2 a 2-page paper in which you:

· Describe at least three ways that culture can influence group dynamics.

 

Submit a 2-page paper in which you:

· Describe at least three ways that culture can influence group dynamics.

· Analyze how a group leader might intervene with sensitivity to issues of diversity in a group setting.

· Identify a diverse population and describe at least three methods you might use to intervene with sensitivity.

Use the Learning Resources to support your Assignment. Make sure to provide APA citations and a reference list.

Three periods of prenatal development

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Choose  two (2) questions to answer. Each answer should be one typed double-spaced page in length.

Indicate, in full, by question number, the question you are answering. You do not have to copy out the question. Submit your answers in order. Your answer to each question is expected to be about one typed double-spaced page in length. You must use complete sentences and proper grammar. Use a typical font and size (we can tell if you change the margins in order to submit a longer answer!).

Answer questions in your own words using your own examples rather than those of the text. If Canadian data is available, be sure to include it in your answers. References are not required because the only source needed to answer these questions is your text. If you do use outside sources, then you must provide the full citation; you will not improve your mark, however, by using outside references.

Questions

1. Compare cross-sectional and longitudinal research designs. What are the advantages and disadvantages of each? Give an example of each. What design has emerged that is based on the advantages of these designs?

2. Compare and contrast any two theories discussed in Chapter 2.

3. Why are males more likely to suffer from sex-linked recessive disorders? How can a female have the disorder?

4. Describe the three periods of prenatal development. Why is the second stage the most dangerous for the developing child?

5. Discuss the kinds of low birth weight that affect a baby. What are the short and long-term consequences?

See the Assignment Schedule for the due date. Submit using the Dropbox.

Parenting advice for parents of adolescents

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an audience of parents of adolescents to help them relate to the changes your children will be going through. Complete the following in your presentation:

  • Explain the changes their children will go through related to adolescence, including:
  • Physical changes
  • Cognitive changes
  • Social changes
  • Neurological changes
  • Explain changes in behavior they will likely see in their children, including:
  • Risky behavior
  • Inconsistent judgment
  • Increased desire for independence and how it relates to brain functioning
  • Discuss behavioral issues common in adolescence, including:
  • Identity crises
  • Challenges related to fitting in
  • Teen suicide
  • Discuss parenting advice for parents of adolescents.

Developing questions and hypotheses

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Developing questions and hypotheses about workplace motivation is one of the most important steps to understanding and applying the theories of motivation in the workplace. This week, you will look more closely at this vital part of theory building and how you can go about developing quality application-focused ideas, questions, and hypotheses. First, provide an analysis of your own experience with workplace motivation through unsystematic and systematic observation and issues that can help you to develop sound research. Second, how would you apply your ideas regarding workplace attitudes that impact motivation?

Next, go the PG Library and find a scholarly research article on one of the theories discussed and relate it to a topic of interest regarding workplace motivation and attitudes. Briefly recap the study and provide your evaluation of how well the research adds value to the field of workplace motivation.

Functions of Therapeutic Interview

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Kevin is a 26-year-old male who is suffering from anxiety, depression, and racing thoughts. Kevin was a victim of bullying all through school and has an unfulfilling social life. He has insecurities and appears to have low self-esteem. Kevin’s is in search of purpose and desires to a acquire sense of belonging. Kevin indulges in alcohol and marijuana to pass the time and to compensate for the amount of time he spends alone.

 

 

·

Assignment Details

PY527 MOCK INTERVIEW GUIDELINES

Note: Your written critique of your mock interview will be your Final Paper submission for the course.

·  For this assignment, you are to conduct an initial interview with a fake client in which you will develop rapport, identify current concerns, and provide some structure for future treatment if deemed necessary.

·  The person you interview must use a FICTITIOUS problem and they must not be anyone you know from a professional interaction. They should have a well-developed fake identity prior to beginning the interview (presenting concern, age, ethnicity, family, work, etc.).

·  The mock interview should be a minimum of 45 minutes long. You will record the interview and upload to Blackboard or email me your recording. Your paper will not be graded without submission of the videoed interview.

·  You should use the skills outlined in your book to facilitate engagement, initial stress reduction, establishing rapport, obtaining clarity regarding why the client is seeking services, and assessing what stage of change the client is in.

·  I will not be evaluating your skills; YOU will be evaluating your skills which will require you actually review the video after you conduct the interview. I will evaluate your ability to evaluate your skills.

·  Your written critique should be three to five double-spaced paged. You should begin by providing an overview of the client’s concerns, then discuss your formulation of the problem, then identify the techniques (as discussed in your book) that facilitated the therapeutic process and whether you stuck to the “flow” of the session (see below) and finally outline what you could have done differently. Use APA style.

The Egan text does not discuss the natural “flow” of the therapy session. I believe that an awareness of this structure assists therapists with maintaining purpose and structure in treatment. Below is an overview of this structure as outlined by Kanfer and Schefft (1988).

Functions of the Therapeutic Interview:

1) Information Gathering-connecting current concern with multiple facets of the person

1. Not limited to the first session

2. What is the client’s current life situation?

3. What is the client’s background and family history?

4. Gather info about the client’s educational, social, medical, and occupational history.

2) Assessment

5. Analysis of client’s current complaints, resources, skills, and assets

6. Clarification of the problem (what precipitates it and what maintains it)

7. Assess motivation for change

8. How do education, social, medical factors, etc. affect current presenting concern?

9. Can this client self-regulate emotion/behavior?

Updated: 08.03.18

f. What type of supports does this client have?

3. 3)  Information giving

1. Directive

2. Brief

3. Always check in with client to be sure the information you provided was understood

and correctly interpreted

4. 4)  Instigation of change

1. Re-evaluate goals

2. Practice change behaviors in session

5. 5)  Production of change

1. Assigned homework

2. Description of next step

3. Review/identify improvements

Structure Across Sessions

1. 1)  Early Sessions-primary task of the clinician is to structure the interactions where changes are planned, evaluated, and supported. Therapeutic alliance is the main agenda

1. 2)  Middle-facilitate action in client’s daily life

1. 3)  Later Sessions-client takes primary responsibility in direction session

Structure of the Therapeutic Hour

1. 1)  The opening

9. Eases the client into the treatment structure

9. Between session events and moods are considered and used for transition into the

session

1. 2)  Preparation of the central theme

10. Identifies goals for the session

10. Assists client with participation in the process

1. 3)  Engagement and resolution of the central theme (this will not be paramount in the initial

interview-the central theme at this point is if the client will continue with treatment)

11. Deals with the current problems and strategies to resolve it

11. This is the period of highest emotional intensity of the hour

1. 4)  Recapitulation and summary

12. Reviews what was discusses (using client’s words)

12. Prepares for tasks to be completed to address concerns

1. 5)  Winding down and closing

13. Assist client with disengaging from the therapeutic process

13. Re-enter life setting

Two-Factor Theory of Emotion

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Emotion Regulation

 

 

 

Student Name

University

Course

Professors Name

Date

 

Things that stood up in the Research

Several things arose concerning emotional regulation in the empirical research that I read. First, the article stated that three components are essential to emotional regulation. This entails initiating action that is triggered by emotions. There is also the inhibiting, and the last one is the modulating response. The article clearly states that the modulating response is core in regulating all the processes involved in the emotion. (Chowdhury & Madhuleena (2021). The article stated that no day ends without coming across a scenario that provokes our emotional stimuli. Some aspects that cause emotion can be positive or negative events.

Another core aspect of the article is that an individual with poor emotion regulation strategies falls into the traps of mood polarities. The behavior and action patterns are controlled by emotion. In contrast, an individual who regulates emotion can balance his feelings, action, and judgment. Another core aspect that arose in the articles is the aspect of the items that govern emotion regulation. These items occur because they dictate an individual control of emotions. The essential aspect is the self–awareness that enables us to monitor how we feel, thus core in emotional regulation.

What did the authors of the study you selected examine in their research? What did they hypothesize and why (rationale)?

The author of the study examined the core aspects of emotion regulation. He gives the six elements that are essential in every person when it comes to emotion regulation. There is an element of the self–awareness that enables an individual having feeling in a specific scenario, thus essential in emotional regulation. There is an aspects of mindful awareness. This element enables an individual to identify his feelings towards the external environment, which allows an individual to gain a certain thought towards something. (Chowdhury & Madhuleena (2021). The third element is Cognitive reappraisal, which dictates an individual’s thinking capacity. These aspects has a central role in the acceptance of a specific scenario. In the Adaptability aspect, the author examines how this element lowers life’s adaptability as a result of emotional deregulation.

The author hypothesizes that distraction affects emotion .This distraction enables the mind to shift from the state of rest and tries to cope with the rise scenarios. In giving out the rationale, the author states that the acts of self-compassion enable an individual who is free from distractions and emotions. Unfortunately, those people who are not prone to distractions when it arises are unable to cope as they are not used to emotional regulation skills. The aspect of emotional support states that a person has mental energy capable of responding to emotions.

Method used

The method used in collecting data was the use of the questionnaire. In that, 187 college students were used, which entailed 40 men, 133 woment, and 14 who had missing data on their gender. The mean age of the participants was 23.9 years, and the ethnic composition entailed 53.1% Caucasian, 11.2% Asians, 1.1% Native-American, 7.1% African-American, 11.7% Latino/Hispanic, and 1.6% Middle-Eastern. The participants were recruited using the online portal. The participant were told about the importance of the study and they were given 21 days to fill in the survey.

Meaningful findings from the author’s research

Some of the research findings stated that two factors result in emotions. This includes the physiological arousal and cognitive label of physiological state. Some feelings and arousals are initiated in mind based on one’s environment. These feelings can either be good or bad based on the processing of information in mind. The research also found that a perspective mind enables the managing of emotions. Once an individual has feelings, it triggers the mental and physical attitude. The element of physical arousal has a central role in controlling emotion. From the research, it was found that the occurrences of emotional situations help in the development of an adaptive feature. The aspect of arousal compose a wide range of emotions; thus, physical arousal cannot only be a cause of emotional responses.

Limitation to study

Several limitations are subject to this study. First, the measure used was a self-report that the participant filled out at the end of the day; thus, problems associated with self-report were minimized; therefore, they were not eliminated. Another limitation is that the 14 participants failed to fill in gender data and therefore could not comprehensively analyze the data based on the genders.

How do the findings from this study help you better understand the content?

Through this study, I can appreciate several things that not only help in understanding the week’s contents but also play an essential role in understanding the aspects of emotions. I can appreciate that reappraisal is a core aspect of the feeling that helps change how an individual thinks concerning something that triggers emotions and offers a response. The aspect of suppression is normally linked to a negative outcome of something or a scenario. One way an individual can help in controlling emotion is to stop paying much attention to something that distracts the mind. A person should be willing to accept feelings to avoid much distraction. It is essential to avoid some stressful scenarios in life so that they trigger emotions. I can also appreciate that emotions are natural and unavoidable but there can be a mechanism to control them. There are trained therapists capable of helping people with channels of controlling emotions.

Parts 2

Hypothesis:

Null Hypothesis: There is a relationship between feelings and beliefs of inferiority in individuals living with ADHD.

Alternative Hypothesis: There is no relationship between feelings and beliefs of inferiority in individuals living with ADHD

Statistical test

The test used in the study is a correlation; it will be used to show the mutual relationship between the feelings and beliefs of inferiority in participants.

Graph

The graph consists of two variables which are used in testing the correlation. The X-axis consists of the Cognitive (Believes and knowledge) variable while in the Y axis consists of the Affection (Feelings) variables

 

 

Response

The Research: Is: there is a relationship between feelings and beliefs of inferiority in individuals living with ADHD? The variable in this research study is feelings and beliefs. The scale used in this study is the Attitudes towards Mental Health Problems Scale.

 

References

Chapter 26: Suri, & Gross, (2016). Emotion regulation: A valuation perspective. In L. Feldman Barrett, M. Lewis, & J. M. Haviland-Jones (Eds.), Handbook of Emotions, 4th Ed. (pp. 453-466). New York, NY: Guilford Press.

Article: Coan & Gottman, J. M. (2007). The specific effect (SPAFF) coding system. In J. A. Coan and J. J. B. Allen (Eds.) Handbook of Emotion Elicitation and Assessment (pp. 106-123), New York, NY: Oxford University Press. Coan, J. A. & Gottman, J. M. (2007). The specific effect (SPAFF) coding system. In J. A. Coan and Allen (Eds.) Handbook of Emotion Elicitation and Assessment (pp. 106-123), New York, NY: Oxford University Press. – Alternative Formats

Web Article: Emotion regulation strategies in daily life: mindfulness, cognitive reappraisal, and emotion suppression

Chowdhury & Madhuleena (2021). Positive Psychology. What is Emotion Regulation? + 6 Emotional Skills and Strategies.

Psychology Today. (2021) Sussex Publishers, LLC. Emotional Regulation.

Cherry, Kendra. (2019) Very Well Mind. The Schachter-Singer Two-Factor Theory of Emotion

Qualitative and quantitative findings

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This assignment is a research project that will report your quantitative and qualitative data. You will use some of the work you have already completed in your other assignments to create a final research paper. In addition, you will add new elements to your paper by revising your literature review and creating a methods and results section to elaborate upon your research and your qualitative and quantitative findings. You will write a final report that follows APA guidelines:

 

It will include all of the following sections: Title page, Abstract, Introduction, Literature Review (using at least 8 sources), Methods (how you collected your data), Results (Quantitative and Qualitative), Conclusion, Limitations, Future Directions, and References. You do not need to include footnotes/endnotes.  I suggest looking at the format of some of the academic journal articles you have read to mirror what they have done. You will use in-text citations to reference the academic literature you have in your review. You are required to state your research questions, hypotheses, define your variables and how you measured them, analyze and interpret your quantitative and qualitative data appropriate to answering the question, and write your results in a manner that is easy to understand (even for someone who is not a social scientist)! Use chapters 20 and 21 as a reference guide for reporting your quantitative and qualitative results. I understand that many of you have not had experience yet using a statistical software program and have varying levels of experience when it comes to analyzing data. Therefore, you will have some flexibility analyzing your quantitative data. You can use excel to look for correlations and create charts, etc. You can also create tables to show the frequencies of responses from your respondents and report on the associations you do see. You will also report the themes found in your qualitative interviews. If applicable, you can quantify your qualitative data by creating a table to identify the frequency with which certain statements, ideas, or themes occurred. I expect that your paper will be 15-20 pages (double-spaced), including a title and reference page. The  Research Project rubric will be used for grading.