Lesson 8: Taking Histories


Attention


Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Describe how to gather and document a client's social history

Teaching

Gathering the Story

Gathering information for the social history is very important. This information helps determine your impressions and recommendations for treatment.

A "social history" is a description of the history of the problem that has brought the client to services. It also includes all the relevant background information about the person because these factors may contribute to the problem as well.

We might envision this as the persons' "story".

DETAILS are what are important...you may have heard the saying that the "Devil is in the details"...this might be true, but the solution to the problem is often there as well!

This is why it is so important to NOT jump to conclusions and solutions too early in the case management relationship...take the time to get to know the details of the story.

Information we Need

Click HERE to review the Maine DHHS standards for assessment

Ongoing Story-Gathering

As a CM, part of our relationship building function with our clients is to continue to get to know them and their history over time. We will never have the WHOLE story but if we remain open to the conversation, we can learn a lot.

This app is called the Professional Case Management Journal app and is free. This app allows users to read the journal articles from this professional peer reviewed journal. In this lesson I am going to ask you to read a specific journal article using the app.

Go into the app and open the journal for May/June 2015. Read the article titled: Assessing the Whole Person: Case Managers take a Holistic Approach to Physical and Mental Health by Carter, Zawalski, Sminkey & Christopherson (Vol 20, # 3).

 


Assessment

Lesson 8 Assignment

Using the interview you conducted last week write up a treatment plan based on the examples provided below. Submit a written treatment plan to the Lesson 8 Assignment Drop box that includes all of the necessary information in an organized and logical format.

Here is the example Treatment Plan for T.C. (MS Word Version)

Here is the example Treatment Plan for T.C. (PDF Version)