2. • Referral (Including source and reason)
• Medical History
• Personal/Family History
• Education
• Work History
• Personality and Habits
Requirements:
• Submit a Word document that includes a title page.
• Be sure to address each section fully. Each area of information
can be broken
into sub-sections, listed with the appropriate heading.
• This is a professional report and should use formal language,
complete
sentences, proper grammar and appropriate sentence structure.
Be sure to read the criteria below by which your work will be
evaluated before
you write and again after you write.
Social History Assignment
4. Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
Presenting
Problem
Section missing or
major details
missing.
Section addressed.
Some key details
missing.
Section addressed
in detail. Sub-
sections used with
headings when
appropriate. Minor
detail(s) missing.
Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
Referral
5. (Including
source and
reason)
Section missing or
major details
missing.
Section addressed.
Some key details
missing.
Section addressed
in detail. Sub-
sections used with
headings when
appropriate. Minor
detail(s) missing.
Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
Medical History Section missing or
major details
missing.
Section addressed.
Some key details
6. missing.
Section addressed
in detail. Sub-
sections used with
headings when
appropriate. Minor
detail(s) missing.
Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
Personal/Family
History
Section missing or
major details
missing.
Section addressed.
Some key details
missing.
Section addressed
in detail. Sub-
sections used with
headings when
appropriate. Minor
detail(s) missing.
Section addressed
in full detail. Sub-
7. sections used with
headings when
appropriate.
Education Section missing or
major details
missing.
Section addressed.
Some key details
missing.
Section addressed
in detail. Sub-
sections used with
headings when
appropriate. Minor
detail(s) missing.
Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
Work History Section missing or
major details
missing.
Section addressed.
Some key details
missing.
9. Section addressed
in full detail. Sub-
sections used with
headings when
appropriate.
0 – 11 Points 12 – 15 points 16 – 19 points 20 points
Clear and
Professional
Writing
Errors impede
professional
presentation.
Significant errors that
do not impede
professional
presentation.
Few errors that do
not impede
professional
presentation.
Writing and format
10. are clear,
professional.
Joe Brown (DOB 01/11/1930) is an 85-year-old straight, Black
male who was recently
admitted to the hospital after his youngest daughter found him
lying on the floor in the
bathroom. His daughter estimates that he may have been on the
ground overnight. Mr.
Brown was admitted to the hospital and diagnosed with a right
side stroke that left him
with moderate weakness in his left arm and leg. Mr. Brown was
also diagnosed with
dementia.
According to his youngest daughter, Jean, Mr. Brown has been
living on his own in a
two-story home. He has lived here for 60 years and has been
alone for over 2 years
after his wife passed away. Mr. Brown has two daughters, Jean,
who recently moved in
with her father after losing her job, and Catherine who lives 4
hours away with her
family. Mr. Brown is a retired school teacher and is described
as a private man who
does not like having visitors at home.
The hospital social worker got Mr. Brown to agree to shopping
assistance and a weekly
cleaning service. It is also noted that Mr. Brown has not
identified anyone to have power
11. of attorney or any authority to help with finances and bill
payments.
Jean reports that she and her sister Catherine have a tense
relationship that worsened
when their mother passed away. The two are currently
disagreeing about Mr. Brown’s
discharge destination and any time it is discussed, Jean and
Catherine argue and the
conversation ends with no solution. Mr. Brown says he will be
fine once he is back in his
own home, especially with Jean’s support, however, Jean is
relutanct to agree to extra
services as she knows her father would not want this. Catherine
feels that Mr. Brown
should transition into an assisted living or nursing facility and
is concerned that Jean is
not coping well or being realistic.
Mr. Brown’s medical history indicates that he has Type II
Diabetes and is insulin
dependent. He also has been admitted to the hospital on several
other occasions
recently—twice for a urinary tract infection and once for a fall
related to having low
blood sugar. Mr. Brown currently needs assistance to get in and
out of bed as well as
help with his hygiene. However, Mr. Brown is able to walk
short distances with a walker
Mr. Brown shares that he receives Social Security benefits as
well as retirement pay
which is why he does not qualify for support services like food
stamps or cash
assistance. He gets by each month and is able to maintain his
bills. However, Mr.
12. Brown cannot recount how much money is in his accounts or the
value of his home. He
appeared to be confused by some questions but was generally
pleasant and willing to
engage in conversation. Mr. Brown says he knows he needs help
but is not willing to
live in a residential facility.
HSV340 – Case Management
Case Vignette
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