Prepare A Genogram For The Client You Selected. The Genogram Should Extend Back By At Least Three Generations (Great Grandparents, Grandparents, And Parents)
I will provide a client without violating HIPPA these are the areas need to be addressed in the genogram Demographic information Presenting problem History or present illness Past psychiatric history Medical history Substance use history Developmental history Family psychiatric history Psychosocial history History of abuse/trauma Review of systems Physical assessment Mental status exam Differential diagnosis Case formulation Treatment plan
Pain Today (0-10): Pain is described as 1 out of 10. Allergies: NKDA SLEEP ISSUES: Hours of sleep per night: 6-7 Snores: No Sleep latency: 0-15 min Daytime Somnolence: No Substance History: Caffeine Use: No Cups/Date Equivalent: Tobacco/e-cigs: none Packs/Date Equivalent: Illicit drug use: denied DEVELOPMENTAL/SOCIAL HISTORY: Patient reports that he grew up in Mississippi. His father died in a motor vehicle accident when he was several months old. Raised by his mother and stepfather. Denies any abuse history. Never married. Has a bachelor’s of arts in communication from Grambling UNIV. reports that he worked at Lowe’s during college and thereafter. Is an AGR Soldier within the United States Army reserves in Mississippi from 2012-2018. States that his religion and spiritual values preference being Christian. Patient was primarily raised by Biological parents and that childhood was generally Good. Patient denies ever being physically, sexually or emotionally abused. Highest level of education achieved is: 4-year college degree or equivalent. Patient is currently single and currently lives with Other. Housing is currently Off-Post. Patient reports religion, faith or spirituality DO play an important role in life. Social support reported as satisfactory. Patient reports the following history of legal issues: None of the above. PAST FAMILY/MEDICAL HISTORY: Family Medical Illnesses: None Family Behavioral Health Illnesses: None Family Substance Use History: None OBJECTIVE MSE Orientation: ☐None ☒Place ☒Object ☒Person ☒Time Attention: ☒Normal ☐Distracted ☒Other: Maintained focus and attention throughout the session. Appearance: ☒Neat ☐Disheveled ☐Inappropriate ☐Bizarre ☒Other: dressed in civilian attire. Behavior: ☒Cooperative ☐Guarded ☐Withdrawn ☐Agitated ☐Stereotyped ☐Aggressive ☒Other: calm Eye Contact: ☒Normal ☐Intense ☐Limited ☒Other: maintained appropriate eye contact during the session. Psychomotor: ☒Normal ☐Restless ☐Tics ☐Slowed ☐Other Speech: ☒Normal rate, volume, and rhythm ☐Tangential ☐Pressured ☐Impoverished ☐Other Mood: “I feel good overall.” Affect: ☒Congruent with mood ☒Euthymic ☐Anxious ☐Angry ☐Depressed ☐Euphoric ☐Irritable ☐Constricted ☐Flat ☐Labile ☐Other Thought Process: ☒WNL ☐Circumstantial ☐Tangential ☐Loose Associations ☐Disorganized ☐Other Thought Content: ☒WNL ☐SI ☐HI ☒ potentially paranoid ☐A/V hallucinations ☐Delusional ☒Other: Denies SI/HI plan or intent Memory Impairment: ☒WNL ☐Short-Term ☐Long-Term ☐Other Insight: ☐Good ☒Fair ☐Poor Comments: Judgment: ☐Good ☒Fair ☐Poor Comments: BHDP: Behavioral Health Vitals (patient reported): Overall health reported as: Good Pain Level (0-10): 0 Currently treated: N/A Suicidal Ideation Risk – C-SSRS-S score: 0 Past/Prep Behavior last 3 months: N/A # past attempts as of 12/07/2016: 2 Most recent Suicidal Ideation: N/A Suicidal Ideation Duration: N/A Suicidal Ideation Frequency: N/A Protective Elements Stopping Suicidal Actions: Faith/Religion, Family, Hope for future, Friends, Other Harm Others Risk over next week as of 12/18/2018 – None Active Plan: N/A Patient with access to weapons: No Recent Outcome Measures (last 30 days) BASIS24 – Score: 0.56 – Subclinical to low level of general distress reported (12/18/2018) PHQ9 – Score: 4 – Depressive syndrome unlikely (12/18/2018) GAD7 – Score: 3 – Anxiety syndrome unlikely (12/18/2018) PCL-5 – Score: 3 – None-Low PTSD symptoms reported (12/18/2018) PCL-C: N/A AUDIT: N/A CSI – Score: 8 – Possible relationship distress reported. Evaluation indicated. (11/30/2018) ISI – Score: 9 – Subthreshold insomnia (12/18/2018) BAM: N/A LABORATORY RESULTS: Reviewed laboratory results ASSESSMENT Patient Strengths: ☐ None reported ☐ motivated ☐ insightful ☐ committed ☐ Tx compliant ☒ family support ☐ social support ☐desires change ☐ previous positive BH experience ☐ desire to address longstanding issues ☒ good expressive language ☐ good ego strength ☐ Other: Patient Barriers: ☐ None reported ☐ unmotivated ☐ limited insight ☒ uncommitted ☐ Tx non-compliant ☐ limited family support: ☐resistant ☐co-morbid Dx ☐ previous negative BH experience ☒ limited social support ☐cognitive impairment/TBI ☐low ego strength ☒ Other: Not resistant but questions the validity of his behavioral healthcare SAFETY RISK ASSESSMENT ☐YES ☒NO History of Suicidal Ideation: ☐YES ☒NO History of Suicidal Planning: ☐YES ☒NO History of Suicidal Gestures: ☐YES ☒NO History of Suicidal Attempts: ☐YES ☒NO Close friends/family who have attempted/completed suicide: ☐YES ☒NO History of intentionally harming others or destroying property: ☐YES ☒NO Current intentions to engage in above behaviors: ☐YES ☒NO History of impulsive-taking: Risk Factors: ☐None reported ☒Male ☐Impulsive ☒Weapons access ☐Legal Stressors ☐Financial Stressors ☒Occupational conflict ☐Chronic medical problems ☐Substance abuse: ☐Abuse victim: ☐History of suicidal gestures ☐History of family/friend suicide ☐Relationship problems ☐OTHER: insomnia Protective Factors: ☐None reported ☐Married ☐Children ☒Positive religious coping ☒Future orientation ☒Healthy coping skills ☐Active treatment participation ☒Supportive spouse ☐Supportive family ☐Social support ☒PT wants to continue treatment ☐OTHER: This provider considered the above risk/protective factors and has determined the following risk level: RISK: Harm to Self – ☒Not Elevated ☐Low ☐Intermediate ☐High Harm to Others – ☒Not Elevated ☐Low ☐Intermediate ☐High SAFETY:☐YES ☒NO Imminent threat to self. ☐YES ☒NO Imminent threat to others. ☐YES ☒NO Imminent threat of harm from other individuals. ☒YES ☐NO Patient is fully able to make informed medical decisions and manage affairs. ☒YES ☐NO Patient is unlikely to withhold information about SI/HI ideation or intent. ☒YES ☐NO Patient is considered to be a reliable source of information. DIAGNOSTIC FORMULATION: This is a 35-year-old male who was deployed to the Middle East as an individual unit augmentee. He reports that he became an conflict with his leadership over mishandling funds, and other ethical related issues. The unit is making the claim that the patient is misperceiving these incidences, based off of the provider assessment in-theater; paranoia over this situation was identified. DSM Diagnosis(es) Code: Other occupational structure stressors R/O: Delusional Disorder, psychosis Estimated Treatment Prognosis: Good . PLAN Treatment Summary: 1) Patient was provided psychoeducation, assessment of current functioning, risk/safety assessment, development of rapport, development of treatment goals, empathic listening and directed questioning techniques to elicit information and provided supportive environment to facilitate patient insight. Patient was provided active listening, strategic reflection, encouragement and validation. Other therapies discussed include: 1. Diaphragmatic Breathing 2. Progressive Muscle Relaxation 3. Safe Place Imagery 4. Mindful breathing 5. Problem solving techniques 6. Sleep Hygiene 7. Discussed, Virtual Hope box, Tactical Breather, Moving forward and Mindfulness coach apps available on smart phone. 2) Discussed open-access clinic available at BH clinic. Pt agree if symptoms worsen or if new behavioral concerns arise, Pt to call, RTC, or if after duty hours, go to ED and/or call emergency line. Limits to confidentiality were discussed with the patient as appropriate. 3) Attending behavioral health group for deployed service members on Monday, Tuesday, Thursday and/or Friday from 1430-1600. Medications: None Risk/Suicide Management Plan: ☒YES ☐N/A The patient will follow-up in therapy to address treatment goals. ☒YES ☐N/A The patient has demonstrated the ability to and has agreed to make use of a crisis response plan. ☐YES ☒N/A The patient was added to the High Interest Program to track continuity of care. ☐YES ☒N/A Persons notified: ☐YES ☒N/A Emergency Contacts: ☒YES ☐N/A Emergency Contacts and Crisis Response Plan: Call friends, family members, or a trusted chaplain. Contact Military One Source at http://www.militaryonesource.mil/ or call 00-800-3429-6477. Call Wounded Soldier and Family Hotline at OCONUS DSN 312-421-3700. Access www.realwarriors.net/livechat for online chat support. After duty hours, call 112, call MPs, First Sergeant or primary supervisor if feeling suicidal. During duty hours, walk in to Behavioral Health Clinic. Go to the Emergency Room at Landstuhl Regional Medical Center. They will call the on-call Behavioral Health Provider. ☐YES ☒N/A Safety plan worksheet uploaded into HAIMS.
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