The following are format of Case Studies to keep Records of Patients / Clients data collected by the aspiring Psychology Students. These are must be followed to have a clear view of problem facing by client and suggested therapy need to be taken from time-to-time.
As you can say Client data is confidential, yes but until unless you don't reveal their full name and address of their location.
Before taking below information, first you have to establish Rapport with the Customer / Client.
Same is applicable for all Counseling / Clinical / Organizational Psychologists.
Title: Case History
Regd No.:
Date:
Consultant & Supervisor:
Socio-Demographic Data:
1) Name : (just use initials, not to reveal real identity)
2) Age:
3) Gender:
4) Education:
5) Socio-Economic Status:
6) Marital Status:
7) Occupation:
8) Religion:
9) Resident:
10) Informant:
11) Information:
Chief Complaints:
12) Duration, Course & Onset (of Illness)
History of Present Illness:
13) Past History
14) Family History
15) Personal History
16) Educational History:
• In School/College:
• How is the patient in studies and academic performance?
• Does the patient come up to the expectations of parents and teachers?
• How has the performance been over the years?
• Do they find that there is sudden deterioration in studies and academic performance?
• Have they received any complaints from the school authorities regarding the patient’s
performance?
• Since when have they noted that the patient is not the same in regard to academics as he or
she used to be?
• Have they done anything about it so far? If so, what?
• Had there been any improvement after their efforts?
• When did they decide to consult a mental health specialist?
Mental Status Examination (MSE):
It may take as little as five minutes to examine a healthy person. Patients with speech problems or intellectual impairments, dementia, or other organic brain disorders may require fifteen or twenty minutes. The examiner may choose to spend more time on certain portions of the MSE and less time on others, depending on the patient’s condition and answers.
A complete MSE is more comprehensive and evaluates the following ten areas of functioning:
1) Appearance. The psychologist notes the person’s age, sex, and overall appearance. These features are significant because poor personal hygiene or grooming may reflect a loss of interest in self care or physical inability to bathe or dress oneself.
2) Movement and behavior. The psychologist observes the person’s gait (manner of walking), posture, coordination, eye contact, facial expressions, and similar behaviors.
Problems with walking or coordination may reflect a disorder of the central nervous system.
3) Affect. Affect refers to a person’s outwardly observable emotional reactions. It may include either a lack of emotional response to an event or an overreaction.
4) Mood. Mood refers to the underlying emotional “atmosphere” or tone of the person’s answers. Whether the person is in a sad mood, happy mood, angry mood etc.
5) Speech. The psychologist evaluates the following:
a) the volume of the person’s voice
b) the rate or speed of speech
c) the length of answers to questions
d) the appropriateness of the .answers
e) clarity of the answers and similar characteristics
6) Thought content. The examiner assesses what the client is saying for indications of the following which are indicative of certain typical disorders. Each of the following will have to be checked by the learner/ trainee.
17) Work history:
• What occupation is the patient involved?
• How regular is the patient for work?
• Has the patient been complaining about work place? If so what?
• Has the patient been on leave? If so for how long?
• When was the time they noticed that the patient was reluctant to go for work?
• What reasons were given by patient for not attending to work?
• Generally how has the patient been fairing in work?
• Has there been any complaint about non performance etc. about the patient?
• What is their perception about patient’s relationship in the workplace?
With Boss:
With colleagues:
With subordinates:
• Has the patient ever mentioned about anyone bothering at workplace? How much importance
have they given to patient’s such complaints?
18) If Married: Relationship with spouse in terms of
• Day to day dealings
• Sex life
• Work relationship (if spouse is working)
• Relationship with children
• Relationship with opposite sex persons
• Decision making (who takes the decision - spouse or self)
• Sharing of work at home with the spouse
• Relationship with spouse’s relatives
• Relationship with spouse’s friends
Therapy Session:
19) Short-term goals
20) Intermediate goals
21) Long-term goals
Steps to be followed during the session are given here:
Step 1: The learner must pay close attention to the following regarding the client:
• Client’s presentation
• Client’s personal appearance
• Client’s social interaction with office staff and others in the waiting area
The case history, psychological tests administered, verbatim record or sessions and intervention planned, etc. should be included case-wise in the Internship report by the learner.
• Whether the client is accompanied by someone (This helps to determine if the client has social support)
The above few observations can provide important information about the client that may not otherwise be revealed through interviewing or one-to-one conversation.
Step 2: When client enters the office, pay close attention to the following:
• Note the personal grooming
• Note things as obvious as hygiene
• Note things such as whether the client is dressed appropriately according to the season
• Note if client is talking to himself or herself in the waiting area
• Note if the client is pacing up and down outside the office door
• Record all observations
These types of observations are important and may offer insight into the client’s illness.
Step 3: Establish rapport
The next step for the psychologist is to establish adequate rapport with the client by introducing himself or herself. Speak directly to the client during this introduction, pay attention to whether the client is maintaining eye contact. Mental notes such as these may aid in guiding the interview later. Note if clients appear uneasy as they enter the office, then immediately attempt to ease the situation by offering small talk or even a cup of water. Many people feel more at ease if they can have something in their hands. This reflects an image of genuine concern to clients and may make the interview process much more relaxing for them.
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