CLIENT ASSESSMENT AND TREATMENT PLAN
Topic: CLIENT ASSESSMENT AND TREATMENT PLAN Number of Pages: 8 (Double Spaced) Number of sources: 6 Writing Style: APA Type of document: Research Paper Academic Level: Master Category: Nursing ATTACHEMENTS; Order_Files_775879_1.pdf Order Instructions: The Assignment; my patient’s name is JACK PIE DATE OF BIRTH IS 03/26/79 PRIMARY PHONE NUMBER IS 210 000 000 Name of emergency contact: HC BIG ( girl friend) Emergency contact phone number:111 111 111 Culture: American LANGUAGE: ENGLISH RACE: Black Ethnicity: African American DATE OF SERVICE :3/16/18 Time of service: 8:00am -9:30 am Duration of service:1:30 Presenting problem/chief compliant: I dont know how to cope with my sister’s death who died of breast cancer” With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations): 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 Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).
PRELIMINARY TREATMENT PLAN
For this assignment, you will continue to develop your work with the one of the ten cases you identified and began working with at the face-to-face residency. Open the Preliminary Treatment Plan and complete the information in the online form for the tabs titled “Biopsychosocial” and “Treatment Plan.” Once completed, download a PDF and submit it to your instructor in the assignment area by the end of this unit.
For your course project, you will further develop a biopsychosocial and treatment plan for one case study subject that you previously selected from eight possible candidates. During the course of this project you will:
•Evaluate client information and articulate the presenting problem.
•Review possible assessment techniques.
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•Create short and long term treatment plan goals.
•Discuss the legal and ethical concerns.
•Identify areas of consultation with other professionals.
•Develop a suggested treatment plan for the client.
TODD’S CASE
Todd, a 66-year-old African-American man, recently retired after 40 years of teaching high school social studies and coaching, to tend to his wife and two grandsons. He needed to be home to take care of his wife, who has advancing Alzheimer’s. Mike is also the guardian for his two grandsons, ages 9 and 12. The grandsons became his and his wife’s responsibility two years ago, after the death of their daughter due to a drug overdose. Todd loved teaching and did not want to retire, but felt overwhelmed by family demands. So far, he is “holding it together,” but is afraid his social isolation due to caring for his family is going to “pull him under.”
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