Consider the multicultural perspective while reading this line from the chapter: For many individuals, the medical establishment represents a place where they have little knowledge, no power

Generalist Case Management A Method of Human Service Delivery 5th Edition

Marianne R. Woodside Tricia McClam

CHAPTER 9

Building a Case File

Introduction

Case Files: collection of information about the client, gathered over time by various professionals.

The type of information needed for the case file depends on the individual’s case and the agency’s goals. Many cases involve medical, psychological, social, educational, and vocational information.

The Purpose of the Case File, Slide 1

Case files serve several purposes:

Summarizing the work with the client from the eligibility assessment through the end of services and after-care.

Providing data for evaluating client outcomes and the effectiveness of agency services and assessing the need for changes to the agency mission, goals, and services.

Providing data for answering legal and financial accountability questions (e.g., how were resources spent).

Providing new case managers with information during case transfers.

Case files address two facets of case management: working with the whole person and providing documentation and maintaining good records.

The Purpose of the Case File, Slide 2

The purpose of building a case file shifts during the case management process.

At first, case managers build a case file to determine service eligibility.

After eligibility is established additions are made to the file and may include assessments, case management plans and revisions, case notes, rationale for service termination, final outcomes, aftercare and follow-up plans, and the client and the case manager’s evaluation of services.

Medical Evaluation

Knowledge of medical terminology, conditions, treatments, and limitations is important in understanding a case.

Medical information may be provided on a form or in a written report.

Agencies approach medical information in different ways.

Medical knowledge is particularly crucial when working with people with disabilities; the information determines limitations and informs objectives.

Medical evaluations consist of recommendations, including the individual’s physical, emotional, and intellectual capacities.

It is important when referring a client for a medical exam that the case manager prepare the client for that experience. This is especially critical from a multicultural perspective. Some individuals may feel diminished authority in the presence of medical professionals.

Medical Exams, Slide 1

Medical diagnosis: general health status appraisal of an individual. Determines whether a physical or mental impairment is present.

Diagnostic medical services include general medical exams, psychiatric evaluations, dental exams, exams by medical specialists, and lab tests.

A diagnosis may provide important information about social and psychological aspects of the case in addition to medical aspects.

Medical consultation: communication with a medical professional who may help interpret available medical data, determine any implications for health and employment, and recommend further medical care if needed.

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.

Medical Exams, Slide 2

Physical examination: exam in which a physician obtains information concerning a client’s medical history and states findings. The medical service used most often in human services.

Diagnosis: obtaining a complete medical history and conducting a comprehensive physical exam.

Clients may need an explanation of why a diagnostic or physical exam referral is necessary, the amount of time the exam will take, what outcome is expected, and how the information will be used.

Medical Terminology, Slide 1

Medical terminology: technical words and phrases used by physicians.

Case managers must have at least a rudimentary understanding of medical terminology in order to make sense of medical reports.

Four elements are used in medical terms: a) The word root—the main part or word stem. b) The combining form—the word root plus a vowel (usually o). c) Suffix—the word ending. d) Prefix—the word element located at the beginning of a word.

To work out the meaning of a term: identify the suffix and its meaning, find the prefix (if any) and determine what it means, and identify the root words and their meanings.

Medical Terminology, Slide 2

It is a continuing challenge for case managers to keep current with terminology because of ambiguities, inconsistencies, and the changing course of medical knowledge.

Keeping informed about trends in medicine increases one’s understanding of the meaning of terms.

Keeping current with medical terminology entails awareness of chemicals, syndromes, and diseases that are newly named and sometimes given acronyms or abbreviations.

Case managers must remain mindful that words can have multiple meanings and that several names may apply to a single entity.

Word Roots

Word root: the main part of stem of a word.

The root usually derives from Greek or Latin and often indicates a body part.

All medical words have one or more word root.

Combining Forms

A word root plus a vowel, usually an o.

For example, the word root cardi when used with the combining vowel o becomes cardio, meaning heart.

Suffixes

A suffix is a word ending.

In medical terminology, the suffix denotes a procedure, condition, or diseases, or can express size.

For example, the combined form gastro (stomach) when added to the suffix megaly (enlargement) means enlargement of the stomach.

Prefixes, Slide 1

Prefix: the word element at the beginning of the word.

Prefixes usually denote number, time, position, direction, or negation. For example, the prefix micro means small.

To work out the meaning of a term: identify the suffix and its meaning, find the prefix (if any) and determine what it means, and identify the root words and their meanings.

It is a continuing challenge for case managers to keep current with terminology because of ambiguities, inconsistencies, and the changing course of medical knowledge.

Prefixes, Slide 2

Keeping informed about trends in medicine increases one’s understanding of the meaning of terms.

Keeping current with medical terminology entails awareness of chemicals, syndromes, and diseases that are newly named and sometimes given acronyms or abbreviations.

Case managers must remain mindful that words can have multiple meanings and that several names may apply to a single entity.

Psychological Evaluation

Psychological evaluation: a behavioral or mental health evaluation that contributes to the understanding of the client.

Referral

Case managers may refer clients for psychological evaluations for a number of reasons:

To establish a diagnosis in order to meet criteria of eligibility for services.

To provide justification for a particular service.

To obtain information about a client’s personality, aptitude, interests, intelligence, and achievement.

To resolve contradictions or ambiguities or to add information that is missing.

To answer particular questions regarding the client.

Part of making a successful referral is specifying the need for the exam and preparing the client for the psychological evaluation.

The Process of Psychological Evaluation

The evaluation itself includes a study of past behavior, conclusions drawn from observations of current behavior, a diagnosis, and recommendations.

As a consultant, the psychologist decides what kinds of data must be gathered to carry out the assignment given by the referral source, which findings have relevance, and how these findings can be most effectively presented.

The Psychological Report, Slide 1

Psychological report: a written document that explains an individual’s personal characteristics, mental status, and social history.

This document provides information that helps to determine what are the problems and challenges facing the client and what might be possible interventions.

The Psychological Report, Slide 2

The report may appear in one of several forms, the most common of which is narrative.

The components of the report include orienting data (the reason for the referral and pertinent background information), illustrative and analytical content (interpretation of raw data), and conclusions (diagnosis and recommendations).

Sources of information for a report are the interview between the psychologist and the client; test data; behavior observed during the evaluation; any available medical reports and social histories; and any observations, case notes, or summaries written by other professionals involved with the case.

The DSM-5

DSM-5: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition provides a way of classifying mental disorders through a multi-diagnostic approach.

DSM-5: has four features that focus on diagnosis.

Level 1 Cross-Cutting Symptom Measures: self-report assessment questionnaires focusing on symptoms that can appear regardless of primary diagnosis (American Psychiatric Association, 2013b).

Level 2 Cross Cutting Symptom Measures: assessments specific to a disorder.

Specifiers expand the description of the features of a disorder and help clinicians target treatment for multiple disorders.

Life span development describes how symptoms manifest at different stages of the life cycle.

Social History, Slide 1

For a complete case file, the client’s past history and present situation must be investigated.

Social history: provides information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships.

Advantages include: completes the picture of a client, may provide a better assessment of the client’s needs, may fulfill legal requirements, and can help build the relationship.

Limitations include: categorizations and judgments may be premature, excessive questioning may lead to a dependent role for the client, cultural questions may create barriers to the relationship, may give an inaccurate view of what will happen, and some clients may construe it as therapy.

Social History, Slide 2

Taking a social history is a time to continue to build the relationship with the client.

Social histories are taken within the context of the culture of the client (treat clients with cultural sensitivity).

The following areas may appear in a social history: identifying information, presenting problem, referral, medical history, personal and family history and current family situation, education, work history, economic situation, personality information.

The client provides most of the information for a social history, but other sources may also contribute.

Other Types of Information

Educational

Educational information can have many parts: test scores, classroom behavior, relations with peers and authority figures, grades, suspensions, attendance records, and indications of academic progress such as repeated grades and advanced work.

Vocational

Vocational information may include jobs previously held, the ability to get along with co-workers, work habits, and reasons for frequent changes in employment.

This additional information rounds out the case manager’s understanding of who the client is—strengths, weaknesses, abilities, and aptitudes.

References

American Psychiatric Association (2013b).

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