Taking the Affected person’s Historical past
Every task on this course will assist you to put together your Remaining Paper. For every task, you’ll use the film character or historic determine you selected in your Week One journal. Bear in mind, after submitting this week’s task, you’ll not be allowed to alter your film character or historic determine.
One of many first steps in any medical evaluation is to collect a radical historical past from the affected person. This historical past contains, at minimal, the affected person’s figuring out info, presenting downside, and related private historical past referring to their presenting downside.
For this task, you’ll write the primary few sections of your psychological report. View the entire directions for the Remaining Paper within the hyperlink inside Week 5 of your on-line course or the “Parts of Course Analysis” part of this information. This week, your task should cowl the next sections of your psychological report and embody the headings as listed:
- Figuring out Info
Inside this part, you’ll describe fundamental info in your affected person, together with the individual’s identify, intercourse, gender, sexual orientation, age, race, occupation, and site of residence (nation, state, and area).
- Chief Criticism/Presenting Drawback
Inside this part, you’ll embody the affected person’s main grievance verbatim to establish and describe the principle supply of his or her misery and/or considerations. If there is no such thing as a verbatim grievance, embody observable info to create an total image of the presenting downside.
Usually, this part inside a psychological report seeks to reply the next query (additional elaboration inside this part is inspired the place attainable):
- What are the affected person’s complaints? (e.g., the affected person would possibly complain about “feeling on edge” or experiencing stress)
- You’ll not be finishing part III of the Remaining Paper for this week’s task.
- Private Historical past
Inside this part, you’ll describe your affected person’s private background and historical past of irregular conduct(s) that inform your diagnostic impression. Additionally, you will collect details about the affected person’s cultural background and cultural norms.
Usually, this part inside a psychological report seeks to reply the next questions (additional elaboration inside this part is inspired the place attainable):
- The place did the affected person develop up?
- What cultures did the affected person expertise all through life?
- What was the affected person’s faculty life like?
- What have been his or her grades? What’s his or her highest degree of schooling?
- What’s the affected person’s interpersonal relationship historical past?
- What was/is the affected person’s romantic relationship historical past?
- What was/is the affected person’s friendship historical past?
- Household Historical past
Inside this part, you’ll describe the affected person’s familial relationship(s) and establish any abnormalities that may have an effect on future therapy. Additionally, you will combine details about the affected person’s household and cultural background to establish any maladaptive behaviors and relational patterns.
Usually, this part inside a psychological report seeks to reply the next questions (additional elaboration inside this part is inspired the place attainable):
- How previous have been the affected person’s dad and mom when the affected person was born?
- Who have been the affected person’s main caregivers?
- What was/is household life like? (Embody any info related to your diagnostic impression.)
- Did the household transfer typically?
- What was/is the affected person’s relationship with their siblings (if relevant)?
- What tradition did/does the household come from?
- What perception techniques are hooked up to that tradition?
- Remedy Historical past
Inside this part, you’ll describe the affected person’s remedy historical past to tell your diagnostic impression. Analyze the affected person’s remedy historical past to establish the effectiveness of earlier therapy(s). Consider earlier therapy interventions primarily based on info and data of the affected person’s cultural background.
Usually, this part inside a psychological report seeks to reply the next questions (additional elaboration inside this part is inspired the place attainable):
- Who was the earlier therapist (if any)?
- How lengthy did the earlier remedy/therapies final?
- What was the affected person’s prognosis?
- What interventions did the therapist(s) use?
- Have been these interventions applicable for the affected person’s tradition?
- Was therapy profitable?
