This document discusses the importance of case files in social work practice, highlighting the need for thorough record-keeping and documentation to address legal and outcome accountability. It details various types of information included in case files, such as medical, psychological, and social histories, and emphasizes their role in effective case management and service coordination. Additionally, it covers the necessity of cultural sensitivity during medical evaluations and the processes involved in gathering and utilizing client information to enhance service delivery.

1. Unit 7: Readings
Readings and Resources
Articles, Websites, and Videos:
This chapter focuses on assessment & interview and social
histories.
·
Writing and human behavior in the social environment.
(2018). In Weisman, D., & Zornado, J. L.,
Professional writing for social work practice, Second
Edition (Vol. Second edition). Springer Publishing Company.
This chapter provides an overview of record-keeping relative to
legal issues such as court requests with a focus on analytical
writing.
·
Writing for social work practice. (2018). In Weisman,
D., & Zornado, J. L.,
Professional writing for social work practice, Second
Edition (Vol. Second edition). Springer Publishing Company.
Building a Case File
Chapter 9Chapter Introduction
· Chapter Nine addresses Social Work Case Management
Standard 10, Record Keeping, which is focused on building a
case file.
· Chapter Nine addresses Human Service–Certified Board
Practitioner Competency 4, Case Management, which is focused
on building a case file.
I used to work on a federal grant. The files of our clients were
really important to us. The information from the files helped us
document the work that we did and the outcomes that we had. If
I forgot to record an interaction with a client or if I forgot to
ask for the client feedback sheet from each visit, then we had a

2. hole in the record. We also used our files to provide better
services to our clients. But the pressure from the government
made the second reason appear an afterthought.
—Permission granted from Susan Grant (pseudonym), 2014, text
from unpublished interview
This chapter examines the types of information that may be
found in a case file or that must be gathered to complete one.
For each section of the chapter, you should be able to
accomplish the following objectives.
The Case File
· Describe the reasons why the case file is important.Medical
Information
· Tell how medical information contributes to a case.
· Decode medical terms.Psychological Evaluation
· List the reasons for a psychological evaluation.
· Make an appropriate referral.
· Identify the components of a psychological report.
· Review two psychological reports.
· Describe the type of information provided by the DSM-
5.Social History
· State the advantages and limitations of a social history.
· Name the topics included in a social history.
· List the ways social information may appear in the case
file.Other Types of Information
· List the types of educational information that may be gathered.
· Define a vocational evaluation.
·
9-1Introduction
· The
case file is filled with information about the client
gathered at various times by various professionals. Exactly
which information is needed depends on the individual’s case
and the agency’s goals, but many cases involve medical,
psychological, social, educational, and vocational information.

3. We introduce each type of information, provide a rationale for
gathering it, describe the kinds of data likely to be provided,
and discuss what the case manager needs to know to make the
best use of the report. The following quotations are from
individuals who are currently performing the roles of case
manager. Reading these quotes will help you hear a first-person
front-line perspective of how case managers work with the case
files.
·
When I am at work it is important for me to remember
that I need to know about medical assessments, especially
medical terms and how they are used. I use my computer to
search terms I don’t know. I also have a hard copy of
the Physician’s Desk Reference, although, quite frankly, I
primarily use the Internet. I try to have a basic knowledge of
special therapies like speech therapy or occupational therapy.
·
—Case manager, services for children and families,
New York, New York
·
Our shelter provides mid-term shelter. A few shelters
only provide lodging and services for 4 nights. We allow our
clients to remain with us for up to 30 days. Other shelters’
clients have to commit to a year of residence. For our month,
we provide clients with a wide range of services. We try to meet
all of their needs. Comprehensive assessment is key, and we
provide an on-staff psychologist, group counseling, and
individual and family work.
·
—Director, emergency shelter, St. Louis, Missouri
·
When a child is referred to our agency, we immediately
seek more information. For example, the first thing a case
manager does is contact the school and ask for records. Of
course we have a release from the parents to get the records….

4. We need the school records even if the child is referred for a
medical issue.
·
—Care manager, high school, Los Angeles, California
· The chapter-opening quotations illustrate the kinds of
information that a case manager may need from other
professionals to develop a plan or to provide services. The
medical information, histories, or exams these three helpers
mention are part of the case files of clients who have medical
problems. The case manager providing services for children and
families speaks of the advantages of being familiar with medical
terms and medical references when trying to decipher medical
reports. Physical assessments and psychological assessments
offer important information to the emergency shelter staff as
they work with homeless and runaway female teens.
Professional staff at the high school in Los Angeles gather
much information about the students from other schools.
9-1aThe Purpose of the Case File
A case file serves a variety of purposes and meets various
agency goals. First, the case file provides a summary of the
work with the client from eligibility assessment through the end
of services and aftercare. This summary is important for an
agency to maintain a picture of clients served and the process of
case management and outcomes. The record may also be useful
for the client if the client needs a record of services to share
with other human services agencies. Case files also can provide
information useful for evaluating outcomes and assessing
possible changes to agency mission, goals, and services.
Information in case files help answer accountability questions
that agencies must answer. These questions include, “What
resources do you have available?”, “How did you spend these
resources?”, “What services did you provide?”, and “What were
the client outcomes.” At times, difficult issues may arise and
the agency or case manager may need the records to address
malpractice issues.

5. Finally, agencies are committed to provide quality care to their
clients. Part of that quality of care includes effective responses
in times of crises and efficient transition of services as
practicing case mangers leave the organization and new staff
assume the responsibilities of those leaving. An in-depth case
file allows new case managers to establish rapport with and
understand their clients and where they are in the case
management process.
In summary, the case file directly addresses the critical nature
of two facets of case management, that of working with the
whole person and that of providing documentation and
maintaining good records. This helps in the process of service
coordination. Careful attention while building the case file is
important for several reasons, including legal accountability,
financial and outcome accountability, and effective client
services.
The purpose of building a case file shifts during the case
management process. For example, when an individual is
applying for services, the case manager begins to build a case
file to determine if the individual applicant is eligible for
services. Once eligibility has been established, the information
previously gathered becomes the foundation and provides the
initial data for that file. During the case management process,
additions are made to the file. These additions may include:
· a)
further assessments;
· b)
the case management plan;
· c)
case manager written case notes;
· d)
periodic assessments of the case management plan and process;
and
· e)
revisions of the case management plan.

6. At the end of the case management process, added to the case
file are:
· a)
reasons for ending client services;
· b)
final outcomes;
· c)
plans for client aftercare;
· d)
plans for follow-up;
· e)
client evaluation of services; and
· f)
case manager evaluation of services.
Figure 9.1 illustrates the various aspects of a case file.
Figure 9.1The Case File during the Case Management Process
So, now let us look at one type of information you may find in a
case file, that of a medical report or a medical evaluation.
9-1bMedical Evaluation
Knowledge of medical terminology, conditions, treatments, and
limitations is important for understanding a case. Medical
information may be provided on a form or in a written report.
The exam and report may have been completed by a general
practitioner or by a specialist in a field such as neurology,
orthopedics, or ophthalmology. In some cases, the case manager
can interact with the medical service provider and thus will be
able to ask questions, request specific assistance, or offer
observations. Often, however, he or she does not have this
opportunity and must rely on the written report. Then, the
resources mentioned at the beginning of the chapter may prove
particularly helpful. Many agencies have a copy of
the Physician’s Desk Reference (PDR) or other medical guide or
may have access to the PDR on a mobile device. Some also have

7. a physician serving as a consultant who is available to answer
questions. This section introduces basic medical information to
help you understand medical terminology.
Agencies approach medical information in different ways. Some
require documentation of a mental or physical disability or
condition when determining eligibility for services. Others use a
medical examination as part of their assessment procedures. In
certain situations, medical information is not gathered unless
there is some indication or symptom of a disease, condition, or
poor health that would affect service delivery.
Medical knowledge is particularly crucial when working with
people who have disabilities. A general medical examination
and specialists’ reports help determine the person’s functional
limitations and potential for rehabilitation. It is important to set
objectives that are realistic in light of the client’s physical,
intellectual, and emotional capacities. When a medical report
covers a disability in functional terms:
[I]t addresses the following factors [and] the description can
read like the following: strength, climbing, balancing, stooping,
kneeling, crouching, crawling, reaching, handling, fingering,
feeling, talking, hearing, tasting, and smelling, near acuity, far
acuity, depth perception, visual accommodation, color vision,
and field of vision. (Debates, Rondinelli, & Cook, 2000, p. 81)
Each medical evaluation includes recommendations relating to
the individual’s physical, emotional, and intellectual capacities.
What follows is a sample medical recommendation.
The individual has a diagnosis of obsessive-compulsive disorder
and has limited strength, balancing, hearing, and near-acuity
functionality. This person needs work with supervision, few
stressors, and limited lifting.
Often, however, the form for a general medical examination
allows only a small space for the diagnosis, so the case manager
reads a phrase such as “chronic back pain,” “normal exam,” or
“emotional problems.” Not very helpful, is it? Remember that
the client is an important source of information; he or she can

8. tell you about any problems. You may then need to decide
whether or not a specialist’s evaluation would be helpful.
It is important when referring a client for a medical exam that
the case manager prepares the client for that experience. This is
especially critical from the multicultural perspective. For many
individuals, the medical establishment represents a place where
they have little knowledge, no power or authority, or have had
previous difficult experiences. Many case managers find that
the best resource for culturally sensitive physicians is the client
himself or herself. When you follow-up on a medical referral,
you can ask clients about their experiences.
Voices from the FieldConducting Culturally Sensitive Medical
Exams
An approach to medicine that is client-centered is important.
The University of Washington (2009) uses guidelines to educate
and train their medical students regarding how to conduct an
interview. The guidelines that follow provide case managers
with specific ways they may assess the sensitivity of the
physicians conducting the medical exam.
Cultural sensitivity in this setting means
· “Appreciating the ethno-cultural, spiritual, and religious
perspectives of patients, families, and communities. … The
term cultural humility, coined by Tervalon and Murray-Garcia
(1998), expands this to include the recognition of power
dynamics in health care and the community at large and
encourages physician advocacy to address imbalances” (p. 77).
Goals of culturally sensitive medical interviewing and their
responsibilities related to each follow.
· Demonstrate contextual sensitivity and use cultural sensitivity.
Be aware of family, cultural, and religious values and the
influences of gender, age, socioeconomic status, and education
level.
· Gather information regarding patient and family perspectives
on, and use of, traditional and/or complementary healing
strategies.

9. · Exploring and understanding the approaches patients have
used in treating their illness is very important.
· Eliciting this type of information may be challenging.
Historically, some patients and family members have been
misjudged and even chastised by healthcare professionals for
admitting use of alternative or traditional remedies.
· Be cautious and sensitive when trying to elicit this important
information.
· Be attentive to any verbal or nonverbal cues that the patient
may be uncomfortable discussing alternative healthcare
practices (i.e., silence, eye deviation, a shift in their seated
position, crossing their arms, etc.).
· Questions such as the following may be helpful to ask:
· Have you seen anyone else about this problem besides a
physician?
· Who do you think gives you good health advice?
· Who else do you trust?
· Have you participated in any healing practices or ceremonies
to treat your problem?
· Have you used nonmedical remedies or alternative or
traditional treatments for your problem?
· What role do they serve in your care?
· Who in your family or community advises you about this
condition?
· How common is this condition in your family and/or
community?
· What is done commonly to heal this illness?
The University of Washington suggests a model to guide the
cultural sensitivity of the physician during the medical exam.
· Beliefs about health (What caused your illness/problem?)
· Explanation (Why did it happen at this time?)
· Learn (Help me to understand your belief/opinion.)
· Impact (How is this illness/problem impacting your life?)
· Empathy (This must be very difficult for you.)
· Feelings (How are you feeling about it?)

10. 9-1cMedical Exams
Generally, medical information contributes to a case in two
ways.
Medical diagnosis appraises the general health status of
the individual and establishes whether a physical or mental
impairment is present.
For example, 10-year-old Javier Muldowny comes into state
custody, abandoned by his parents. A case manager at the
Department of Children’s Services assigns an assessment, care,
and coordination team to provide support to Javier. One member
of the team takes him to the agency’s health department for an
examination. The examination results in a diagnosis of otitis
media.
Diagnostic medical services include general medical
examinations, psychiatric evaluations, dental examinations,
examinations by medical specialists, and laboratory tests. A
medical diagnosis is helpful when the client has a medical
problem or is currently receiving treatment from a physician
who may provide important information about social and
psychological aspects of the case in addition to the medical
aspects. When making a referral for a medical diagnosis, the
case manager should help the client understand why the referral
is necessary, the amount of time it will require, what the client
can expect to learn, and what use the agency will make of the
report.
Medical consultation is used in several ways. First, the
consulting physician can provide an interpretation of medical
terms and information.
For example, Javier Muldowny was diagnosed with otitis media.
The case manager received this report, asked a colleague what
the diagnosis meant, and learned that it was an ear infection. A
consultation with a physician would reveal that otitis media is a
severe ear infection that sometimes results when the eustachian

11. tubes are not properly angled. The consultation might also
explain the report further and clarify possible treatments. In
Javier’s case, the case manager may need further information
about the advantages and disadvantages of two possible
treatments: insertion of tubes in the ears or a regimen of
antibiotics. A consultation with an otorhinolaryngologist (ear,
nose, and throat specialist) could shed light on the medical
prognosis and the extent of any hearing disability that might be
expected.
The role of a medical consultant is to interpret the available
medical data, determine any implications for health and
employment, and recommend further medical care if needed.
The case manager can make the best use of a consultant by
being prepared for the meeting, perhaps specifying in writing
what is needed from the consultant. This usually involves
identifying problems that need to be resolved and setting forth
the significant facts of the case. 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.
The medical service used most often in human services is the
physical examination, whereby a physician obtains
information concerning a client’s medical history and states his
or her findings. The exam data are entered into the medical
record. Here, we give an overview of the physical examination,
including the kinds of information obtained and what the case
manager needs to know to make such a referral and to
understand the physician’s report.
Diagnosis involves obtaining a complete medical history and
conducting a comprehensive physical exam (also called
a physical, a health exam, or a medical exam). The results of the
exam may be reported on a form provided by the referral source.
Sometimes physicians use preprinted schematic drawings of
various body parts or organ systems to enhance or clarify the
written report. However the information is transmitted, the

12. quality of the reporting depends on the relationship between the
physician and the patient. In some cases, the patient may have
mixed feelings about the referral for a physical exam. He or she
may need an explanation of why the referral is necessary, the
amount of time the exam will take, what outcome is expected,
and how the information will be used. Keep in mind that the
client’s socioeconomic status, language skill limitations, or
cultural background may also influence how he or she feels
about the referral. If the request is communicated with
sensitivity, and if a good relationship with the physician is
established, then the client can overcome any barriers of
anxiety, depression, fear, or guilt.
The general medical exam is conducted by a physician who
takes an overall look at the person’s medical state. Its purpose
is to evaluate the person’s current state of health, focusing on
two areas. First, a complete medical history records all the
factual material, including what the client states and what the
physician infers from what is not said. A typical starting point
is the chief complaint (symptom), as expressed by the
individual. If there is an illness present, then it is described in
terms of onset and symptoms (including location, duration, and
intensity). A family history relates significant medical events in
the lives of relatives, particularly parents, grandparents,
siblings, spouse, and children. Extensive information about the
individual’s medical history is also collected. This may include
childhood diseases, serious adult illnesses, injuries, and
surgeries. A review of symptoms focuses on information about
present and past disorders, which the physician elicits through
questions about organs and body systems. After completing the
physical exam, the physician records a diagnostic impression.
The actual diagnosis is made once there is conclusive evidence,
which may mean performing further studies or referring the
client to a specialist for consultation.
Class DiscussionUsing Culturally Sensitive Guidelines for

13. Exams and Reports
As an individual, in a group, or as a class, review the
Voices from the Field: Conducting Culturally Sensitive
Medical Exams. Describe several ways that you might apply the
culturally sensitive principles when helping your client prepare
for the medical exam. Information you gained in
Chapter Six may also help your planning.
Share the results of your discussion with your classmates.
What exactly comprises a medical exam? Techniques used
during a physical exam are inspection, palpation (feeling),
percussion (sounding out), and auscultation (listening). Usually,
the examining physician works from the skin inward to the
body, through various orifices, and from the top of the head to
the toes (Felton, 1992). Special instruments are used to look,
feel, and listen. More time is spent in particular areas to
ascertain whether a certain finding truly represents a change in
an organ or tissue. Some parts of the exam are performed
quickly, and others require more time. More important areas
may receive a second, more thorough, examination. The
physician records the findings as soon as possible after
completing the exam and shares the results with the client.
For some clients, one of the first things occurring in the case
management process is a referral to a physician for a general
medical exam. This occurred in Sharon’s case, when Tom
Chapman referred her. As the physician conducts the exam, he
or she completes a form like the one shown in
Figure 9.2, which is then sent to the referring
counselor. It becomes part of the client record.
Figure 9.2 is the form completed by Sharon’s primary
care doctor, Dr. Jim Brown.
Figure 9.2Medical Examination Form

14. In
My Story: Sharon Bello, Entry 9.1, she talks about her
experiences with doctors and her reactions after she read the
medical report prepared by Dr. Jones that you viewed in
Figure 9.2.
My StorySharon Bello, Entry 9.1
I feel like I have been involved with doctors for such a long
time. Between my dad dying, having kids, losing two sons,
having my car accident, having two surgeries to try to fix my
back after my accident at the senior center, and now needing
more medical information to receive rehabilitation services, all
of this doctoring and reports, well, it just seems like a lot. For
my case management services, if you remember, Tom Chapman
asked me to get a letter from Dr. Alderman about my surgery.
And I had a long appointment with Dr. Brown for my physical
exam. Tom prepared me well for that exam. I knew why I was
going and I also knew what to expect.
This is the first time that I have ever read an actual doctor’s
report. I contacted Dr. Brown’s office 2 weeks ago to let him
know that reading it was important for a project I was involved
in. Dr. Brown thought reading the report would be a good idea.
The written report looks different from just participating in the
examination and answering questions. I remember, at first, I
was afraid that something during the exam would happen and
then I would not be able to receive the services. But that didn’t
happen. Still, when I read the report, there are a lot of words
that I didn’t know and didn’t understand.
What it does look like is that I am fairly healthy. It is just the
state of my back that is giving me trouble but, well, that pain
when I move is enough for me. Honestly, how my back is, it
influences me every day. I guess when the doctor said that I am
limited in all ways of moving, he was telling Tom how bad
some of my life is for me. And when he said that there was no
way to improve my back beyond what has been done, that pretty

15. much sums up what I know and explains why I sometimes feel
like giving up.
I also saw that Dr. Brown indicated that I was showing ways
that I am depressed. Dr. Brown told me that he sees depression
differently than most other doctors. I am not sure that I
understand what he meant. He says I could have trouble getting
out of bed in the morning and cry several times per day when I
think about my boys. He says those signs might be just a normal
reaction to very difficult experiences. And that might be
different than actually having a diagnosis. He thinks a
psychologist or psychiatrist might have to figure out if I have
depression.
9-1dMedical Terminology
Reports from healthcare providers often include
medical terminology, which may seem like a foreign
language to a case manager who is unfamiliar with it, because
physicians rely on technical words and phrases for exactness.
Medical specialties also have special terminologies. Other
professionals who may write reports using medical terminology
are dentists, podiatrists, veterinarians, pharmacists, nurses,
physical therapists, and occupational therapists. It can be a
challenge for the case manager to make sense of these reports;
to do so, he or she must have at least a rudimentary
understanding of medical terminology.
Medical terminology follows simple rules. To analyze medical
words, identify the four elements that are used to form such
words: the word root, the combining form, the suffix, and the
prefix. It may help to think of these elements as verbal building
blocks. Let us examine each component.Word Roots
The main part or stem of a word is the
word root. In medical terminology, the root usually
derives from Greek or Latin and often indicates a body part. All
medical words have one or more word roots.

16. GREEK WORD
MEANING
WORD ROOT
Kardia
heart
cardi
Gastro
stomach
gastr
Nephros
kidney
nephr
Osteon
bone
osteCombining Forms
A word root plus a vowel, usually an o, is the combining form,
as in the following examples.
WORD ROOT
COMBINING VOWEL
COMBINING FORM
MEANING
Cardi
+
O
=
cardio
heart
Gastr
+
O
=
gastro
stomach
Nephr

17. +
O
=
nephro
kidney
Oste
+
O
=
osteo
BoneSuffixes
A suffix is a word ending. In medical terminology, the suffix
usually denotes a procedure, condition, or disease, as in the
instances listed here.
COMBINING FORM
SUFFIX
MEDICAL WORD
MEANING
arthr (joint)
+
-centesis (puncture)
=
arthrocentesis
puncture of a joint
thoraco (chest)
+
-tomy (incision)
=
thoracotomy
incision in the chest
gastro (stomach)
+
-megaly (enlargement)
=

18. gastromegaly
enlargement of the stomach
Suffixes also form adjectives, express relative size, indicate
surgical procedures, and express conditions or changes related
to pathological processes. Examples follow.
ADJECTIVES
EXAMPLE
MEANING
-al (means “pertaining to”)
arterial
pertaining to an artery
-ible (indicates ability)
digestible
capable of being digested
RELATIVE SIZE
EXAMPLE
MEANING
-ole (means small)
arteriole
a small artery
-ule (means small)
granule
a small grain
SURGICAL PROCEDURE
EXAMPLE
-ectomy (means “removal of an organ or part”)
appendectomy
PATHOLOGY
EXAMPLE
-mania (means “excessive excitement or obsessive
preoccupation”)
PyromaniaPrefixes

19. The word element located at the beginning of a word is
the prefix. It usually denotes number, time, position, direction,
or negation.
PREFIX
WORD ROOT
SUFFIX
MEDICAL WORD
MEANING
hyper (excessive)
+
therm (heat)
+
ia (condition)
=
hyperthermia
condition of excessive heat
micro (small)
+
card (heart)
+
ia (condition)
=
microcardia
condition of a small heart
Other common prefixes that modify word roots indicate position
(e.g., ab means “away from,” as in abnormal), quantitative
information (e.g., a or an means “without,” as in anorexia, or
without appetite), qualitative information (e.g., mal means
“bad,” as in malfunction), and sameness or difference
(e.g., homo or hetero). For other prefixes and suffixes that are
common in medical terms, see
Table 9.1.

20. Table 9.1Common Prefixes and Suffixes
Prefix
Meaning
Suffix
Meaning
dys-
Bad, painful, difficult
-itis
Inflammation
macro-
Large
-algia
Pain
hypo-
Under, below
-toxin
Poison
scler-
Hard
-oma
Tumor
tachy-
Rapid
-pathy
Disease
hyper-
Over, above, excessive
-osis
Abnormal condition, increase
eu-
Normal
-glycemia
Normal blood sugar
There are three basic steps to working out the meaning of a
medical term. First, identify the suffix and its meaning. Second,

21. find the prefix, if any, and determine what it means. Third,
identify the root words and their meanings. For
example, thermometer consists of a suffix (meter, meaning
“instrument for measuring”) and a word root (thermo, meaning
“heat”). Thus, a thermometer is an instrument for measuring
heat. Another example is gastroenteritis. The suffix
is itis (inflammation), the prefix is gastr (stomach), and the
word root is enter (intestine). Gastroenteritis is an inflammation
of the stomach and intestine. Remember that the vowel o is a
combining form, linking one word root to another to form a
compound word. Osteoarthritis is another example. The
suffix itis means “inflammation”; word roots are oste, which
means “bone,” and arthr, which means “joint.” The o is the
combining vowel. Osteoarthritis means inflammation of bone
and joint. The following list contains some common medical
terms that use suffixes, prefixes, and word roots introduced in
this chapter. Can you fill in the columns with the meaning of
each term? Other examples are shown in
Table 9.2.
TERM
SUFFIX/PREFIX
WORD ROOT
MEANING
Tachycardia
Dysfunction
Gastritis

22. Nephritis
Osteopathy
Hypodermic
Table 9.2Some Common Components of Medical Terms
Component
Meaning
Example
-algia
Pain
Neuralgia
angio-
Blood vessel
Angiogram
arth-
Joint
Arthroscopy
contra-
Opposed to
Contraception
derm-
Skin
Dermatology
-emia
Condition of the blood
Polycythemia
enceph-
Brain

23. Encephalitis
glyco-
Sugar
Glycosuria
hepat-
Liver
Hepatitis
hyster-
Uterus
Hysterectomy
leuk-
White
Leukocyte
lip-
Fatty
Hyperlipidemia
-oscopy
Visual examination
Laparoscopy
-ostomy
Creation of an artificial opening
Tracheostomy
-otomy
Incision
Craniotomy
-plasty
Reparative or reconstructive surgery
Rhinoplasty
pre-
Before
Precancerous
pyel-
Pelvis
Pyelogram
syn-
Together

24. Synarthrosis
tri-
Three
Triceps
It is a continuing challenge for case managers to keep current
with terminology because of ambiguities, inconsistencies, and
the changing course of medical knowledge. Although most word
roots have Greek or Latin origins, some occur in both languages
but have different meanings. The root ped, for example, means
“child” in Greek (e.g., pediatrician), but in Latin ped means
“foot” (e.g., pedicure). Many diseases are named for
individuals, such as Alzheimer’s disease, Parkinson’s disease,
and Hodgkin’s disease. Some disorders are called syndromes,
such as Cushing’s syndrome and Horner’s syndrome. Acronyms
are formed from the initials of lengthy terms, such as MRI
(magnetic resonance imaging) and ACTH (adrenocorticotropic
hormone). In addition, medical terminology traditionally uses
hundreds of abbreviations; some of the most common are listed
in
Table 9.3. However, one must be cautious about using
abbreviations because this often increases the likelihood of
error. For example, “qid” mean four times per day, but “qd”
means once per day. If “qd” is interpreted as “qid” and a drug is
administered four times per day rather than once per day, then
serious complications could result. Keeping informed about
trends in medicine increases one’s understanding of the
meanings of terms. For example, physicians increasingly
prescribe generic drugs rather than brand names (e.g., the
generic diazepam rather than Valium®). Keeping current with
medical terminology entails awareness of chemicals, syndromes,
and diseases that are newly named and sometimes given
acronyms or abbreviations (e.g., AIDS for acquired
immunodeficiency syndrome). It must also be remembered that
words can have multiple meanings and that several names may
apply to a single entity.

25. Table 9.3Medical Abbreviations
Abbreviation
Meaning
a.c.
Before meals
b.i.d.
Twice daily
B.P.
Blood pressure
C-1, C-2, C-3
Cervical vertebrae (by number)
CBC
Complete blood count
CNS
Central nervous system
DX
Diagnosis
F.H.
Family history
GI
Gastrointestinal
GU
Genitourinary
HDL
High-density lipoprotein
h.s.
At bedtime
H & P
History and physical examination
L-1, L-2, L-3
Lumbar vertebrae (by number)
LLQ
Left lower quadrant
LMP
Last menstrual period

26. p.c.
After meals
p.r.n.
As needed
q.i.d.
Four times daily
RLQ
Right lower quadrant
RX
Treatment
S-1, S-2, S-3
Sacral vertebrae (by number)
T-1, T-2, T-3
Thoracic vertebrae (by number)
t.i.d.
Three times daily
WBC
White blood count
9-1ePsychological Evaluation
The objective of a
psychological evaluation is to contribute to the
understanding of the individual who is the subject. The report
writer is a consultant who makes a psychological assessment
that is practical, focused, and directed toward the solution of a
problem. Thus, the psychological report he or she prepares is
more than a presentation of data. This section helps you
determine when a psychological evaluation is needed, how to
make the referral, and how to prepare the client. It also
discusses the evaluation itself and the report.
9-1fReferral
Case managers may refer clients for psychological evaluations
for a number of reasons. One reason is to establish a diagnosis
to meet criteria of eligibility for services.

27. Nadine is a deeply depressed 15-year-old who is currently
taking antidepressant medication. She is increasingly out of
control. Yesterday, she slapped her grandmother, with whom
she lives, and threatened to kill her. If she is to receive services
in an inpatient treatment program, then she must have a
diagnosis confirming emotional disturbance.
Another reason for a psychological evaluation is to provide
justification for a particular service.
Amal is a 28-year-old male whose divorce will be final in a
month. As the court date approaches, Amal feels more and more
depressed. He is having trouble getting up in the morning,
showing up for work on time, and maintaining relationships
with those who are close to him. His physician has suggested
counseling, but Amal’s insurance company insists that he needs
to have a psychological evaluation to determine whether or not
he needs it.
Sometimes a psychological evaluation functions as a screening
or routine evaluation to obtain information about a client’s
personality, aptitude, interests, intelligence, and achievement.
Greg is a 35-year-old male who is the only child of elderly
parents. He is developmentally disabled. His parents, concerned
about who will care for Greg if something happens to them,
have learned of a group home where the residents live under
close supervision. One requirement for acceptance into the
program is a recent psychological evaluation that assesses
intelligence as well as ability to function independently.
A case manager may also order a psychological evaluation to
resolve contradictions or ambiguities, or to add information that
is missing.
Paloma is a 10-year-old who is enrolled in public school. Her
teacher is concerned about her behavior. One day she is passive,
rarely interacts with her classmates, and does not participate in
class. The next day, she may be loud, talkative, and disruptive.
Just yesterday, she started a fight with a classmate. This has
prompted her teacher to request an evaluation from the school
psychologist.

28. Finally, a psychological evaluation may be recommended to
answer particular questions regarding the client. Is there brain
damage? Why does the individual have trouble relating to
others? How is this person adjusting to the recent amputation of
her leg? Why is the client doing poorly in school?
In any of these situations, a referral for a psychological
evaluation is appropriate. In each case, the case manager seeks
help to provide the client with needed services. It is easiest to
get what is needed if the consulting psychologist knows the
general mission of the agency and understands the specific
problem to be addressed. Having this information allows him or
her to choose the most relevant and efficient approach to
gathering the needed information. The referral for a
psychological evaluation is usually made by a case manager,
who specifies what is needed: a routine workup, testing,
questions about the case, and a diagnosis. Thus, the
psychologist is charged with a mission. It is therefore critical
for the referral to be more than a general request, such as
“psychological evaluation” or “for psychological testing.”
These terms communicate poorly; the referring professional has
failed to express what prompted the referral. Two scenarios may
result. The psychologist may ask the case manager for more
specific information, or he or she may try to guess what is
wanted or needed. When the reason for the referral is not clear,
it is difficult for the psychologist to provide a useful report.
How does a case manager make a good psychological referral?
First, it is important to be clear about the reason for referral.
The case manager must clarify the need to document a condition
or disability, obtain test scores, or explore behavioral
inconsistencies. Specific questions also help the psychologist
focus on the client’s problems. The psychologist then makes
recommendations to the case manager. The two professionals
can discuss the case before the evaluation to clear up any
questions or needs. Because many referrals are made by phone
or direct personal contact, such a discussion can easily take

29. place, but it may be even more important when the referral is
made in writing.
Part of making a successful referral is preparing the client for
the psychological evaluation. To do this, the case manager
needs a clear understanding of the process and the ability to
explain it to the client. Some clients may be suspicious of
testing or may fear that the case manager considers them crazy.
Demystifying the evaluation helps to dispel these attitudes.
9-1gThe Process of Psychological Evaluation
The evaluation itself includes a study of past behavior,
conclusions drawn from observations of current behavior, a
diagnosis, and recommendations. This study requires the
psychologist to assess which data are important to the client’s
presenting problems. In some cases, relevant information is in
the client file; it is then helpful for the psychologist to have
access to these documents in addition to the observations and
questions from the referral source.
One of the primary ways that a psychologist observes current
behavior is by testing. From the discussion of testing in
Service Delivery Planning, you know that testing gives
samples of behavior. That discussion also introduced a number
of tests that are useful in human services. Psychologists use
many of them, notably the WAIS and projective tests (such as
the Rorschach and Thematic Apperception Test). These tests are
individually administered and scored, and psychologists are
specially trained to use them. As a consultant, then, the
psychologist decides what kinds of data must be gathered to
perform the assignment given by the referral source, which
findings have relevance, and how these findings can be most
effectively presented. We talked in
Chapter Eight about the culturally sensitive approach to
testing; this focus on bias in testing remains important in
psychological testing.

30. 9-1hThe Psychological Report
The results of the psychological evaluation are communicated to
the case manager in a written report. The
psychological report is a written document that explains
an individual’s personal characteristics, mental status, and
social history. This document provides information that helps
determine what problems and challenges the client faces and
what might be possible interventions. The report may appear in
one of several forms, the most common of which is a narrative
(illustrated by the report included in this section).
Results may also be communicated as a terse listing of problems
and proposed solutions. Still another option is the computer-
generated report, usually consisting of a sequence of statements
or a profile of characteristics. Less frequently used are
checklists of statements or adjectives, clinical notes, and oral
reports relating impressions. Because the narrative is the type of
psychological report that is most often used in human services,
let us explore it further.
Usually, the content, sources, and format of narrative
psychological reports follow a similar pattern. There are three
components to the content of a report. One is the orienting data,
which includes the reason for the referral and pertinent
background information, such as age, marital status, social
history, and educational record. Illustrative and analytical
content is the second component; here, one finds the
interpretation of raw data, including test scores. The third
component, the psychologist’s conclusions, includes a diagnosis
and recommendations, which are presented with supporting
evidence. The sources of the information in all three
components 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.

31. Among the headings that organize the report are “Reason for the
Referral,” “Identifying Data,” and “Clinical Behavior.” Under
such headings one would find the reason for the assessment,
identifying information, any social data, and the psychologist’s
observations of behavior during the evaluation. The subsequent
headings—“Test Results,” “Findings,” “Test Interpretation,” or
Evaluation”—may be subdivided into intellectual aspects (e.g.,
an IQ score and what it means) and personality (e.g.,
psychopathology, attitudes, conflicts, anxiety, and significant
relationships). The diagnosis section presents the main
evaluative conclusions, usually expressed as a series of numbers
followed by the name of a disorder or condition.
The diagnosis section of the report may be followed by a
prognosis section—a statement about future behavior.
Recommendations conclude the report and suggest some
possible courses of action that would be beneficial in the
psychologist’s opinion, based on the psychological evaluation.
For an example of a psychological report, see
Figure 9.3.
Figure 9.3Psychological Report, ChildConfidential
Psychoeducational Evaluation Report
Name:
Jaden Clark
Date of Birth:
11/10/2009
Age:
5 years, 10 months
School:
Livonia County Schools
Date(s) of Assessment:
9/19/2015, 09/30/2015
Examiners:
Victoria VanMaaren, B.A.Referral Question(s)
Jaden was referred by his father, Mr. Alex Clark, due to
concerns surrounding hyperactivity and short attention span.

32. While these concerns have yet to impede academic progress,
Mr. Clark reports that he worries these concerns will carry over
into academic concerns soon.Assessment Procedures
Interview(s)
Observation(s)
Wechsler Individual Achievement Test, Third Edition (WIAT-
III)
Behavior Assessment System for Children, Second Edition
(BASC-2), PRS and SRP
Background Information
The following background information was obtained via a
background questionnaire completed by Jaden’s father. Jaden is
a 5-year-old male who is in kindergarten at a Livonia County
school. He currently lives in Livonia County with his parents.
He also lives with a sister who is in second grade, and a brother
who is 2 years old. While English is the primary language
spoken in the home, Mr. Clark is fluent in Spanish and is
teaching the children the language. In his free time, Jaden
enjoys playing outside, building Legos, riding his bike, and
watching TV.
Developmental and Medical History: With regard to medical
history, Jaden was born full-term, weighing in at 7 pounds, 15
ounces. Jaden aspirated upon birth and was held in the NICU for
24 hours, began formula at 5 months, and had tubes placed in
his ears at 2 years old. Mr. Clark reported that Jaden met his
developmental milestones within the normal time frame. Mr.
Clark reported no history of accidents or head injuries during
Jaden’s childhood and reported that he was a relatively healthy
child. No family history of learning or attention problems was
reported.
Mr. Clark reported that Jaden is a very healthy eater and
reported no history of familial alcohol or substance abuse.
Social Emotional History: Mr. Clark did not report Jaden
experiencing traumatic events in the past. In terms of attention,

33. Mr. Clark states that Jaden displays difficulty remaining on task
for long periods of time and is easily distracted during activities
that do not maintain his attention or interest. At times, Mr.
Clark claims that Jaden is impulsive and will engage in
conversations as a form of task avoidance. However, Mr. Clark
stated that he believed this behavior to be exploratory in nature
and that it has caused no issues in the school environment.
Academic History: With regard to his educational history, Jaden
is currently in kindergarten. Jaden has never been retained or
skipped any grades in school. He has never participated in
special education programming. Mr. Clark reported no academic
concerns at this time.Relevant Test Behaviors:
Jaden’s testing took place in his home on a Saturday afternoon.
Testing took place at the kitchen table, with adequate lighting.
The kitchen was at a comfortable temperature for Jaden and did
not seem to affect the testing.
Jaden wore shorts and a t-shirt during the testing session and
appeared clean and put-together. He appeared to be in a pleasant
mood for the testing session and was very friendly and
talkative. During testing, Jaden took a break to use the restroom
and talk with his mother. He concentrated in small bursts but
was very persistent during the test. On a few occasions, he
became frustrated when a problem was too difficult and asked if
he could quit. Jaden engaged in conversation with me as a way
to avoid the task at hand on several occasions. Overall, he
seemed focused when determining the answers but off task in
between subtests. Based on my assessment of the testing
conditions, it is my estimation that the testing conditions were
good and the assessment results are considered an accurate
reflection of Jaden’s abilities at this time.Assessment Results:
Please refer to the Appendix for specific results
I. Current Academic Achievement Wechsler Individual
Achievement Test, Third Edition (WIAT-III)
Jaden’s academic skills within the areas of math, reading, and
writing were measured using the Wechsler Individual
Achievement Test, Third Edition (WIAT-III). His performance

34. across each academic area is detailed here.
Reading. Jaden’s overall reading skills are considered average.
Jaden’s scores on measures of early reading skills are average.
Jaden excelled at tasks involving letter group sounds and
rhyming and experienced difficulty with tasks involving
selecting words ending in the same sound.
Mathematics. Jaden’s overall mathematics skills are average. He
completed items and tasks related to problem solving and math
calculation. Jaden performed in the average range on a measure
of numerical operations, where he completed paper-and-pencil
math problems. He was very persistent in completing the
problems and showed agitation when he came to a problem that
he had presumably not yet covered in class. During math
problem solving, where the examiner read math problems out
loud, Jaden scored in the average range. He rarely used the
paper and pencil provided to work out problems, and instead did
much of the reasoning in his head.
Writing. Jaden’s overall written expression skills are in the
average range. Jaden scored in the average range on a measure
of spelling skills. During the alphabet writing fluency task,
where Jaden was asked to write as many letters of the alphabet
as he could in 30 seconds, Jaden appeared distracted and
attempted conversation with the examiner instead of writing
down letters.
II. Current Social/Emotional/Behavioral Functioning Behavioral
Assessment System for Children, Second Edition (BASC-2)
Jaden’s behavioral, social, and emotional functioning at home
were measured using the Behavioral Assessment System for
Children, Second Edition (BASC-2). Rating scales were
completed by Jaden’s father. The BASC-2 includes several
validity scales to provide an estimate of how accurate the
rater’s responses are overall. Validity measures include
indicators of “faking bad,” inconsistent responding, and
patterned responding showing inattention to item content.Parent
Report

35. The BASC-2 parent report includes an overall measure of
problem behavior, the Behavioral Symptoms Index (BSI). The
BSI includes scales of aggression, hyperactivity, withdrawal,
depression, attention problems, and atypical behaviors. Mr.
Clark reported Jaden’s overall problem behaviors to be average
compared to his peers; however, his Hyperactivity Scale is
clinically elevated, which suggests that Jaden may tend to be
overly active, rush through work or activities, or act without
thinking.
The Externalizing Problems Composite measures more overt
behaviors like aggression, hyperactivity, and conduct problems.
On this composite, Mr. Clark reported Jaden to have an elevated
level of hyperactivity when compared to his same-age peers.
The Internalizing Problems Composite is a measure of behaviors
that are not readily seen, like anxiety, depression, and somatic
(physical) symptoms. On this composite, parent-rating results
indicated average levels of anxiety and somatic symptoms when
compared to his same-age peers. Although Mr. Clark reported
Jaden’s depression level to be at risk, there was not a clinically
significant difference between Jaden and his same-age peers.
The BASC-2 includes an Adaptive Skills composite that
measures skills needed to function independently, like adapting
to changes in the environment, leadership skills, social skills,
and daily activity skills. Jaden’s overall adaptive skills at home
were rated as average when compared to his peers. Mr. Clark
rated Jaden’s activities of daily living skills as average,
meaning that Jaden is able to organize chores or other tasks well
and follow regular routines. He rated Jaden’s ability to adapt to
changes in the environment (adaptability), his ability to express
his ideas clearly and communicate in ways that others can easily
understand (functional communication), leadership, and his
ability to interact appropriately with others (social skills) within
the average range.Summary and Recommendations
Jaden is 5 years old and in kindergarten at a Bradley County
School, with no previously reported educational diagnoses.
Results of Jaden’s achievement abilities revealed average

36. achievement. Jaden’s scores on broad measures of reading,
writing, and math are average when compared to other
individuals his age. Jaden’s BASC-2 Parent Form composite-
scale scores were elevated for inattention/hyperactivity.
Specifically, Jaden scored in the clinically significant range for
hyperactivity, which indicates that his hyperactive behavior is
pervasive and at a level that could result in behavior
problems.General Recommendations:
Based on the results of this assessment, recommendations will
be made to improve hyperactivity and attention.
To help with attention and organization:
· Jaden’s parents and teachers should create checklists or to-do
lists for Jaden to fill out as he completes projects, assignments,
and chores. Checklists may be visual or written. Checklists
should also split larger tasks into smaller subtasks. Similarly,
his parents and teachers are encouraged to divide assignments
into shorter parts and allow Jaden opportunities to have small
breaks while working.
· Jaden’s teachers are encouraged to send home daily behavior
report cards. Behaviors recorded may include completing
assignments during independent seat time, asking for help or a
break appropriately, filling in his planner, or checking his work.
To reinforce behaviors, his teacher may have Jaden choose daily
and weekly rewards if he increases and/or maintains goal
behaviors.
· Prior to beginning a task, Jaden should be asked to think about
what will be needed to complete it, including the materials
needed and also all steps necessary for task completion.
· Provide Jaden a “to-do” list or a schedule of daily classroom
activities to tape onto his desk (or somewhere visible). Help
model how to check or cross things off as they are
completed.Strategies to Improve Hyperactivity:
· Provide breaks for exercise or movement. Jaden may exercise
upon completion of a task. Designate a spot in the classroom
where he can go, away from others, to do some brief exercises,

37. such as jumping jacks. To make this break a class-wide activity,
consider playing a round of “Simon Says” with the students.
They can stand next to their chairs or stand in a circle in the
classroom as you play.
· Provide Jaden a “fidget toy,” such as a squishy ball, to keep
his hands busy in a nondisruptive manner when a task does not
require the use of his hands. Make sure Jaden understands the
rules; if the toy becomes a distraction in itself, you will take it
back.Wechsler Individual Achievement Test, Third Edition
(WIAT-III)
Composite
Standard score
Percentile
Written Expression
104
61
Mathematics
103
58WIAT-III Composite Scores
Note: Composite scores have a mean of 100 and standard
deviation of 15.WIAT-III Subtest Scores
Note: Subtest scores have a mean of 100 and standard deviation
of 15.
Subtest
Standard score
Percentile
READING
Early Reading Skills
105
63
WRITTEN EXPRESSION
Spelling

38. 108
70
Alphabet Writing Fluency
98
45
MATH
Math Problem Solving
102
55
Numerical Operations
103
58
Behavior Assessment System for Children, Second Edition
(BASC-2)
Mr. Clark completed the parent version.
Composite
T-score
Percentile rank
Externalizing Problems
61
87
Internalizing Problems
54
68
Behavioral Symptoms Index
58
82
Adaptive Skills
50
47
Composite
Scale
T-score
Percentile rank

39. Externalizing Problems
Hyperactivity
70
96
Aggression
50
57
Internalizing Problems
Anxiety
54
70
Depression
60
85
Somatization
45
34
Atypicality
46
45
Withdrawal
53
66

40. Attention Problems
58
77
Adaptive Skills
Adaptability
51
50
Social Skills
54
63
Activities of Daily Living
46
32
Functional Communication
49
42
Note: T-Scores have a mean of 50 and a Standard Deviation of
10.
This report was prepared by Victoria VanMaaren and used with
permission.
Psychological evaluations differ according to the client’s needs.
The client profiled in
Figure 9.3 was referred for assessment of his reading
problems and to determine his eligibility for special services.
The tests administered and the final report would have been
different if the client had been referred for other reasons (e.g.,
behavioral problems).
9-1iThe DSM-5
DSM-5
The classification system for mental health diagnoses primarily

41. used in the United States is the Diagnostic and Statistical
Manual of Mental Disorders Fifth Edition (DSM-5, 2013a),
published by the American Psychiatric Association. Before
beginning our discussion on the psychology report, we think
additional information on the DSM-5 is important.
Understanding what the various diagnoses and scores mean will
help the case manager understand the diagnoses and how these
translate into the challenges that clients face. At times,
professionals will submit a DSM-5 diagnosis and a treatment
plan. After consulting with the professional, the case manager
may provide supportive services. Let us see what types of
information a DSM-5 manual provides to help the professional
determine a diagnosis for a client.
The DSM-5 (American Psychiatric Association, 2013a) presents
information and diagnostic material in three sections. The first
section introduces the manual and describes guidelines for its
use. The second section presents the 20 categories of diagnoses.
The third section describes additional ways to assess clients.
For example, there are multiple online instruments to help
clinicians view clients in more holistic ways. A cultural
interview guide is included and helps clinicians better
understand how client culture (such as culture, race, ethnicity)
influences mental health (American Psychiatric Association,
2013a). These assessments and interview guides in section 3
help involve the client and gain his or her perspective in the
diagnosis and assessment process.
There are four distinct features of the DSM-5 that focuses on
diagnosis. The purpose of each is to help more fully explain the
diagnosis, provide a guide for treatment, and document
outcomes. First, in an attempt to help the clinician to present a
diagnosis that reflects a more holistic picture of client
symptoms, DSM-5 offers
Level 1 Cross-Cutting Symptom Measures online. These
measures are self-report assessment questionnaires for adults,
parents/guardians (children 6–17), and children (11–17) and are

42. in regard to the symptoms they experience, regardless of a
“primary” diagnosis”. For example, the DSM-5 Self-Rated
Level 1 Cross-Cutting Symptom Measure, Adult, asks the client
to rate 23 problems according to the degree of bother they
experienced for the past 2 weeks: none (not at all); slight (rare,
less than a day or two); mild (several days); moderate (more
than half the days); severe (nearly every day). Examples of the
problems include “little interest or pleasure in doing things”
(section 1, question 1) and “unexplained aches and pains”
(section 5, question 9) (American Psychiatric Association,
2013b).
Second, there is an assessment of severity for each diagnosis.
For a diagnosis, clinicians are asked to assess the intensity of
the diagnosis: very severe, severe, moderate, or mild. In
addition, the DSM-5 offers
Level 2 Cross-Cutting Symptom Measures. These
assessments are specific to the disorder (e.g., Depression,
Adult, Separation Anxiety Disorder, Specific Phobia, Adult) and
help the clinician view the client’s self-rated experience of one
particular diagnosis. For example, there exists a “Severity
Measure for Depression, Adult” (adapted from Patient Health
Questionnaire 9) that includes nine questions (e.g., “little
interest or pleasure in doing things”). This questionnaire is used
as a self-report instrument and asks the patient to rate his or her
experience of the listed symptom over the past 7 days. The
choices of responses are “not at all,” “several days,” “more than
half the days,” and “nearly every day” (American Psychiatric
Association, 2013c). Level 2 Cross-Cutting Symptom Measures
also include self-rating questionnaires for children (aged 11–17)
and clinician-rated questionnaires.
Third, there are “specifiers” for many diagnoses that expand the
description of the features of the disorder. For example, there
are specifiers for major depressive disorder, such as “with
anxious distress,” “with melancholic features,” “with atypical

43. features,” “with psychotic features,” and “with peripartum
onset” that can help further describe the individual’s diagnosis.
In addition, if the clinician is considering a diagnosis of major
depressive disorder, then the clinician may also be able to
identify mixed features specifiers that may include symptoms
related to mania. For example, for those clients demonstrating
primarily depressive-related symptoms, clinicians may also
indicate specifiers such as elevated mood or decreased need for
sleep (American Psychiatric Association, 2013a). As discussed,
this allows the clinician to target the treatment for mixed
symptoms of depression and mania.
Fourth, for each disorder, when appropriate, the diagnoses are
presented in terms of lifespan development (e.g., children,
adolescents, adults). The goals are to describe the dynamics of
mental disorders over time, view the different symptoms related
to the age of the client, and trace how the disorder
experienced at one age might influence the disorder at a later
age. The manual begins its descriptions of diagnoses that
children and adolescents are more likely to experience (e.g.,
neurodevelopmental disorder, depressive disorders, trauma-
related and stressor-related disorders). Within a description of
each disorder, if appropriate, child and adolescent diagnoses are
considered prior to adult symptoms for diagnosis.
Returning to major depressive disorder to illustrate the way the
DSM-5 uses a lifespan approach for diagnosis, a diagnosis for a
child or adolescent includes the presence of either depressed or
irritable mood and the loss of interest or pleasure with three
additional symptoms (MD Wise, 2014). For adults, diagnosis
requires the presence of either depressed mood or loss of
interest or pleasure (note that irritability is included for
children but not for adults). With specific attention to
depressive disorders and children and adolescents, the DSM-5
also includes the disruptive mood dysregulation disorder as a
diagnosis for individuals up to the age of 18 who demonstrate
extreme irritability or uncontrollable, and perhaps violent,

44. behavior. This behavior has to persist for more than 1 year,
occur three or more times per week, and occur in two of the
following locations: home, school, and/or with peers. The
diagnosis is restricted to age: onset is prior to 10 years of age,
not before 6 years of age, and not after 18 years of age
(dsm5.org, 2013).
Class DiscussionComparing Two Psychological Reports (Child
and Adult)
Read through the information presented in the section about
psychological evaluations. Note that there are two very different
psychological reports presented. The first, in
Figure 9.3, is of a school psychologist. This report will
be used by the S-team at Scott’s local school. This is the first
evaluation Scott has had. In this school, the professional school
counselor and the school psychologist co-direct the team
meetings. The second psychological report is a case report. It
involves an adult psychology examination (see
Figure 9.4).
Figure 9.4Psychological Evaluation, Adult
Student: Emma Pathic
Case: DuncanPertinent Elements
Duncan is a 27-year-old male of Scandinavian American
ethnicity brought in for counseling by self-referral. The
presenting concerns were pervasive feelings of sadness and
grief, along with pervasive guilt and inability to control
intrusive thoughts and memories of a recent traumatic event.
From the client’s perspective, he was referred to counseling
services because of his concerns about getting fired from his job
because of his struggles with inattention and absent-mindedness
at work. In the intake interview, Duncan mentioned that he was
involved in a motor vehicle accident (MVA) 6 weeks ago in
which Duncan was the driver, which resulted in the death of his
then girlfriend. This incident made the local television news
headlines, and Duncan is experiencing shame and guilt from the

45. event. The most pertinent elements of this case include
Duncan’s drinking on the night of the MVA, the death of his
girlfriend, his resulting trauma and depressive symptoms, his
regret for drinking on the night of the accident and taking
responsibility, his family history of potential alcoholism and
anxiety, and his concerns about losing his job related to what
seem to be symptoms of dissociation.Social and Cultural
Influences
Duncan lives alone, but in the same city where his immediate
family resides. He has lived in Seattle for most of his adult life.
He is an only child. The cultures that seem to be most
contributing to his/her current experience are Scandinavian
American ethnicity, working class status, and a member of the
millennial generation. These influences have led him to develop
a Protestant work ethic (ethnicity and social class influences)
while also greatly valuing his connection to friends and family.
Of note, many of Duncan’s family are social drinkers and he
wonders if his father is an undiagnosed alcoholic. Duncan
acknowledged drinking alcohol on the night of the MVA. The
strengths that seem most relevant to his current development are
Duncan’s sense of right and wrong, his concern for the well
being of others, and ability to take responsibility for his own
actions.
To place Duncan’s symptoms in context, it is important to note
that there is a family history of panic disorders on his mother’s
side (aunt, grandmother).Clinical Hypothesis: Provisional
Diagnosis and Core Issues
Duncan best fits the profile of a person with posttraumatic
stress disorder (PTSD). He is experiencing nightmares,
avoidance and psychic numbing, and episodes of dissociation
that include flashbacks of the MVA, which started 2 days after
the accident, has lasted more than 1 month, and occurs multiple
times per day for periods of up to an hour at a time. Duncan
exhibits these symptoms in his relationships with his family,
friends, and other professionals in his home, work, and social
environments (e.g., counseling appointments). These symptoms

46. cause distress in terms of Duncan’s overall mood, which has
become increasingly discouraged and sad, if not depressed.
PTSD seems to impair his relationships with others; aside from
his apparent grief, Duncan reported in session that he has
difficulty opening up to people because he is afraid of losing
them. While he has been able to work since the incident, he
reports difficulty concentrating and is afraid of losing his job.
Duncan also fits the profile of a person with unspecified
depressive disorder. Although he exhibits a “blue” or low mood,
Duncan does not report significant appetite or sleep
disturbances, or anhedonia. In addition to not fully meeting the
criteria for major depressive disorder, it is unclear whether his
current depressive mood state is caused solely by his grief of
the loss of his girlfriend (i.e., bereavement). His traumatic
event seems more severe than typically found in an adjustment
disorder. Furthermore, there is evidence in the empirical
literature that trauma often induces states of depression, further
complicating the clinical picture.
Duncan seems to meet the criteria for alcohol intoxication
rather than an alcohol use disorder, because the frequency,
duration, and intensity of his alcohol use is unknown at this
time. An alcohol use disorder could be ruled out. Other
conditions that may be the focus of clinical attention include
Duncan’s threat of losing his job due to dissociative episodes,
diagnosed in DSM-5 as other problem related to employment.
Further and ongoing assessment will be necessary to rule out
major depressive disorder. This diagnosis should be considered
because of his low mood and cannot be ruled out at this time
because the etiology of his low mood has not been determined.
His alcohol use should also be evaluated and carefully
monitored; it is possible that Duncan has an alcohol use
disorder that may be exacerbated following the recent traumatic
event. Any substance use would affect his prognosis by stalling
treatment. Furthermore, medical causes of his symptoms, such
as a closed head or traumatic brain injury, should be ruled out.

47. Neurological testing and/or CT scans seem to be indicated.
Additional information that is important to keep in mind to best
understand Duncan is that he had been dating the girlfriend who
died in the MVA for 3 months. He has no history of drinking-
related driving arrests, and prior to the accident he only had a
few points on his current driving license for
speeding.Theoretical Approach
Regarding treatment needs, Duncan currently seems to meet the
criteria for outpatient service level on the continuum of care. He
may need higher-frequency (e.g., twice weekly) sessions to
begin to stabilize some of his most prominent symptoms. A
more intensive level of care is not indicated at this time because
Duncan is not suicidal or homicidal, and he seems to be
functioning to the degree that he can sustain his current
employment (albeit tenuously).
The theoretical approach that this client would most benefit
from is trauma-focused cognitive behavioral therapy (TF-CBT).
This approach is likely to be successful because Duncan’s
symptoms of trauma need to be reduced for Duncan to
meaningfully attend to other important areas of his treatment.
This would also prevent Duncan from losing his job due to his
inattention, which is hypothesized to comprise dissociative
episodes.Initial Interventions
Initial interventions include writing a trauma narrative, being
trained in relaxation techniques, and processing his narrative
using subjective units of distress (SUDS) scaling. These
interventions directly target PTSD symptoms and are consistent
with TF-CBT. Once Duncan has managed to mitigate his
immediate suffering, deeper themes can be addressed. These
include grief, loss, and guilt from his choice to drink while
driving on the night of the MVA when his girlfriend was killed.
Furthermore, Duncan’s avoidance of interpersonal contact with
others for fear of harming them needs to be
addressed.Transference and Counter-Transference
Potential transference reactions to be mindful of when working
with Duncan include his possible projection of self-blame onto

48. his therapist. Duncan may expect me to chastise him for his own
behavior. He may also struggle with disclosing his innermost
thoughts and feelings for fear of losing another significant
person in his life. As the therapist, I will also be mindful of my
own counter-transference reactions when working with Duncan.
These include my own history with binge drinking, along with
my stereotypes of this problem existing mostly among young
adult males. Some potential power differentials to be mindful of
include my different social class status; I may lack an
understanding of what it means to grow up in a working class
family. I may need to seek supervision and consultation for
understanding Duncan’s working class background and putting
boundaries around my own experience of binge drinking.
Legal and Ethical Concerns
Some potential legal and ethical concerns that may arise in this
case include the potential for Duncan to request me as a
character witness if he is called to court to face charges for his
MVA (and potentially a DUI charge). The basics of
confidentiality, informed consent, disclosure of services
provided, and fee arrangements will need to be addressed from
the outset. In addition, I will use consultation and supervision
to ensure I am receiving any additional support while providing
TF-CBT in a fairly complex case; I will be mindful of
practicing within my bounds of competence and seeking
assistance when needed.
It is hoped that with increased support, Duncan’s distress will
diminish so that his sense of right and wrong, care for others,
and sense of personal responsibility can lead him along the path
of optimal development.Part II. Diagnosis and Treatment
PlanWhat Problem Behaviors/Symptoms Does This Person
Exhibit?
1. Dissociative episodes
2. Psychic numbing and avoidance
3. Distressing intrusive memories
4. Nightmares and distressing dreams
5. Problems with concentration

49. 6. Exaggerated startle response
7. Low mood, if not depressed
8. Self-blame and intropunitive tendenciesProvide a DSM-5
Dimensional Diagnosis for This Case.
309.81 (F43.10)
Posttraumatic Stress Disorder (primary)
311 (F32.9)
Unspecified Depressive Disorder
303.00 (F10.129)
Alcohol Intoxication
V62.29 (Z56.0)
Other Problem Related to Employment
R/O 305.00 (F10.10)
Alcohol Use Disorder, Mild
R/O 331.83 (G31.84)
Mild Neurocognitive Disorder due to Traumatic Brain
InjuryProvide a Brief Treatment Plan for This Case.
Initial Goal (A):
Ability to cope with symptoms of posttraumatic stress
Associated Behaviors/Symptoms:
Dissociative episodes, psychic numbing, and avoidance
Intervention A:
Teach relaxation and mindfulness strategies to assist client prior
to discussing trauma and to prevent client from dissociating or
becoming overwhelmed
Expected Result:
Greater ability to discuss traumatic event
Measured By:
Trauma Symptom Checklist; Session Rating Scale
Achieved By:
Evaluate progress after 10 sessions
Subsequent Goal (B):

50. Address traumatic event directly, once client is ready
Underlying Root Problems:
Avoidance of emotionally processing traumatic event
Intervention B:
When client feels ready, write trauma narrative and process
narrative in a relaxed state (TF-CBT)
Expected Result:
Reduction in avoidance and numbing PTSD symptoms
Measured By:
DSM-5 Severity of Posttraumatic Stress Symptoms scale
Achieved By:
Evaluate progress around 12–20 sessions
Closing Goal (C):
Consolidate and reinforce coping ability
Gains to Consolidate or Generalize:
Continued progress in coping with symptoms of traumatic stress
by verbally sharing without dissociating or feeling overwhelmed
Intervention C:
Openly discussing client’s willingness to be vulnerable with the
therapist, and generalizing this gain to others in his life
Expected Result:
Continued healing from avoidance and numbing symptoms of
PTSD
Measured By:
Trauma Symptom Checklist; Session Rating Scale; DSM-5
Severity of Posttraumatic Stress Symptoms scale
Achieved By:
Evaluate progress after 24–30 sessions
To understand how psychological reports may differ, answer the
following questions about these two reports.

51. 1. Describe each of the clients for whom the reports are written.
How do these two clients differ?
2. What are the purposes for each of the reports?
3. What information does each report present?
4. How does the information in each report relate to the report’s
purpose?
5. As a case manager, how might the contents of each report
influence your work?
6. What questions do you have about the reports?
Discuss your responses to these questions with your classmates.
In
Social History, Alma Grady describes some of her
experiences with both requesting a psychological evaluation for
a client and using the psychological report in the case
management process.
My StoryAlma Grady, Sharon Bello’s Case Manager, Entry 9.2
Because I was Sharon’s fourth case manager, her case file was
filled with information from a variety of sources. Tom Chapman
and Susan Fields had requested assessments from various
professionals about Sharon and her medical, psychological, and
educational status. Tom was the case manager when eligibility
was determined and when Sharon was accepted for services, so
his intake interview and eligibility assessment are in the file.
The service plan that he and Sharon developed is there. In the
file are Tom’s, Susan’s, and Luis’ notes from their work with
Sharon. Also in the file are the reassessment and revision of
Sharon’s plan that she and I developed (see
Chapter Eight).
Two parts of the case file that I am very familiar with are the
psychological evaluations and the social histories of clients. I
am not trained to administer a psychological evaluation, but I
can read and understand them fairly well. And, to prepare for
the new Diagnostic and Statistical Manual of Mental Disorders–

52. Fifth Edition, I have attended two in-service trainings to better
understanding the new diagnostic categories, the diagnoses that
have been eliminated, and the diagnoses that have been added. I
bought the DSM-5 manual and it looks like a brand new book.
My old DSM-4-TR had lots of notes in it and special pages with
colored sticky tape to mark special passages. Because there
have been lots of changes, I think that I will need to attend at
least two more professional development seminars. The more
that I work with the DSM-5, the more questions I have.
One thing that I like about the new DSM-5 is the way we can
see the severity of the diagnosis. When I read that type of
diagnosis, it helps me begin to gauge the type of help the client
might need. This is especially important when a client has been
engaged in substance abuse or has a DSM-5 diagnosis or both. I
also like the cross-cutting assessments. I have one client with a
complicated mental health history. She has had at least four
diagnoses since she was 16. At my request, her psychologist re-
evaluated her using two of the cross-cutting self-assessments.
The psychologist was able to revise the current diagnosis and
refine her depression, now with anxious distress. This changes
how her mental health counselor works with her and how I work
with her as I prepare her for employment.
As far as Sharon is concerned, I will continue to build the case
file. I will need to update her financial records and the financial
commitment that the agency makes to Sharon’s rehabilitation.
And I will also continue to keep my case notes. And we have
her new plan to work from. Sharon and I together will conduct a
6-month assessment. And we will document the contact and
correspondence we have with the college, including
documentation of Sharon’s standing at the college and her
progress toward graduation.
Now that you have a better understanding of the psychological
evaluation and report, let us look at the social history. As we
mentioned in
Chapter Seven, an initial social history is taken during
the application process and during an intake interview. But

53. knowledge of the client continues to grow and, with this
knowledge, the social history becomes more complete.
Remember in
Chapter Six that Alma Grady discovered Sharon’s rich
multicultural background. Once Sharon talked about her father’s
gift, the warmth of his Hispanic culture, Sharon was able to use
aspects of that heritage to lessen her stress. In Entry 6.3 Sharon
wrote
· “Alma says that this talk of happiness and an easing of spirits
are important as I continue my education, I need some of that
lightheartedness to return. We are finding out ways to call it
back.”
9-1jSocial History
For a complete case file, the client’s history and present
situation must be investigated. The person’s past adjustment can
give indications of how he or she will adjust in the future. A
social history also provides information about the way
an individual experiences problems, past problem-solving
behaviors, developmental stages, and interpersonal
relationships. As we mentioned, some of the information in a
social history may duplicate what has been gathered during the
intake interview. In the social history, however, the client can
relate the story in his or her own words, with guidance from the
helper.
A social history has a number of advantages. Often the informal
history contains gaps, but a carefully taken social history
completes the picture. The case manager can then plan the
appropriate integration of services and provide better
information for future referrals. The social history often
includes a better assessment of the client’s need for services;
this is especially helpful for clients who have multiple
problems. A social history can also fulfill legal requirements.
Finally, the process of taking a social history can help build the

54. relationship between the case manager and the client.
The social history also has limitations. History taking is a
preliminary activity in case management, but the client may
perceive it as a phase in which solutions are put in place.
Unfortunately, categorizations and judgments made at this stage
may be premature. The process of taking the history can also
give an inaccurate view of what will happen between the client
and the case manager. Excessive questioning by the case
manager may lead to a dependent role for the client, and
culture-bound questions can create barriers to the development
of the helping relationship. In addition, an exhaustive history is
not absolutely necessary to develop a plan of services; it may be
helpful, but the information gathered may not be relevant to
service delivery. Spending too much time on history taking can
also be harmful. The client may use the process to resist
significant facts. Other clients may construe it as therapy, but it
is not intended as such and may not even be therapeutically
valuable. Despite these limitations, the social history still has
the important function of completing the case file. Moreover,
the case manager can use certain strategies to mitigate the
limitations.Want More Information? Social Histories
Different organizations or agencies use a variety of formats to
collect information for social histories. Use the Internet to
search for various formats. Note the strengths of each one. The
following example, used by the state of North Carolina,
structures an intake interview to determine eligibility for
services and to begin service planning. Compare other forms
you find with this one. What are the strengths and limitations of
each of the forms you find?
Form retrieved from the Department of Human Services, North
Carolina, http://info.dhhs.state.nc.us/olm/forms/dma/dma-
5009.pdf
There are several strategies that can make history taking, social

55. or otherwise, a positive experience for both the client and the
case manager. First, remember that the main concern is the
client, not the completion of a form or a survey. So, it is
important to make sure that the client understands the reasons
and benefits of the data gathering. Second, use this time to
continue to build the relationship with the client. Being
sensitive to the client’s wishes for privacy or need to discuss
some aspect of his or her history will move the relationship
forward. Finally, remember that it is important for the case
manager to guide the interview, so maintaining a balance
between relationship building and completing the interview are
critical.
Using these strategies, the case manager gathers pertinent
information about what appears to be the client’s problem. The
primary source of information is the client, who is encouraged
to tell the story in his or her own way. The helper listens
carefully to what is said, how it is said, and what is not said.
The sequence of events, reactions, feelings, and thoughts are all
taken into consideration as the client relates the history. Note
taking should be kept to a minimum so that important nonverbal
information is not missed.
Social history is taken within the context of the culture of the
client. For example, interviews with individuals who belong to a
collectivist culture must be treated with cultural sensitivity. In a
collectivist culture, the focus is on the importance of the group
rather than the individual. In a collectivist context, individuals
must fit into the group. There is a focus on group values,
beliefs, and needs, and the group influences individual
behavior.
Because of group influences, social history may hold very
different meaning to an individual from a collectivist culture
than it would to a person in the American mainstream. As the
client responds to questions and tells his or her story, there may
be much more emphasis on the family and the community. The
client may not be able to clearly define personal characteristics
or personal problems, but instead will describe them in terms of

56. the group or family. It may appear that the client is avoiding
answering the questions or not taking responsibility for his or
her own behavior, but the client’s experience or history may be
that of the group or the family. It is also possible that the client
may not wish to share his or her story. In many collectivist
cultures, this information stays in the family or in the group.
There is no set form or procedure for taking a social history.
Some agencies use forms to guide information gathering, such
as the social data report shown in
Figure 9.5.
Figure 9.5Social Data Report
Others just provide guidelines for their case managers; as a
result, the length and detail of social histories may vary. In all
cases, the social history is prepared when a comprehensive
picture of a client’s situation is desired. The outline used for
writing it depends on what the agency wishes to emphasize, but
certain topics are almost always included: identifying data,
family relationships, and economic situation. Other areas
emphasized depend on the focus of the agency and the
presenting problem. For example, a social history of a couple
involved in marital counseling might target areas such as family
relationships and psychosocial development. For someone
seeking economic assistance, important areas might be financial
status, income, expenses, and work history. In general, the
following information may appear in a social history.
· Identifying information: Name, address, date and place of
birth, social security number, military service, parents’ name
and address, children’s names and ages.
· Presenting problem: Brief description of the problem.
· Referral: Source and reason.
· Medical history: Relevant hospitalizations, illnesses,
treatment, and effects. Written permission is needed to obtain

57. copies of medical records, if necessary.
· Personal/family history: Family life, discipline, parenting, and
personal development.
· Education: Highest grade completed, progress, records.
· Work history: Training, type and length of employment,
ambitions.
· Present family relationships and economic situation: Family
members, ages, relationships, lifestyle, and income.
· Personality and habits: Interests, disposition, social activities,
personal appearance.
The client provides most of the information for a social history,
but other sources may also contribute. When the case manager
has gathered material from sources other than the client, he or
she should insert it under the appropriate headings, with the
source identified. Direct knowledge is the main source, as in the
following examples.
· She did not come for her first appointment.
· The client drummed his fingers on the table throughout the
interview.
· He states that his goal is to receive a high school diploma and
get a job.
· The client stated that during the past week she and her
husband had three fights.
The next examples are statements of information from other
sources.
· Educational records indicate that the client completed the
sixth grade.
· Her parents report that the client lived with them until her
marriage 2 years ago.
· He was fired from his job for absenteeism.
· A psychological evaluation indicates a mildly retarded 13-
year-old with possible hearing loss.
The social history shown in
Figure 9.6 combines two approaches. The Identifying
Information section is a form that the case manager completes.

58. The remaining sections are a narrative based on information
compiled from several sources (listed at the end of the report).
At this agency, a social history may be compiled by more than
one case manager, and all who are involved in the writing of the
social history sign the written report.
Figure 9.6Social History
Another way social information appears in a case file is
illustrated by the court reports such as those prepared for
juvenile court based on social information gathered by a
caseworker at the state department of human services (DHS).
DHS caseworkers frequently prepare court reports, for example,
if parental rights are being terminated or if the court asks DHS
to investigate a petition for custody. All juvenile court reports
have certain things in common, such as the reason for the
referral to the department and the circumstances of the child, of
both parents, and of the petitioner. Also included is the
recommendation of the department, which the court may or may
not follow. In most circumstances, a caseworker has been to the
home, completed a social history of the family, and obtained a
signed release of information from the petitioner. The
caseworker has also consulted with the law enforcement
agencies, checked references, and obtained as much information
as possible from other sources. The caseworker then writes a
report informing the court as succinctly as possible of all the
relevant information gathered.
9-1kOther Types of Information
Other types of information may be relevant to the case file,
depending on the agency’s mission and services as well as the
client’s problem. Educational and vocational information, the
most commonly needed, are discussed here.
Educational information can have many parts: test scores,

59. classroom behavior, relations with peers and authority figures,
grades, suspensions, attendance records, and indications of
academic progress such as repeated grades or advanced work.
The sources of educational information are just as varied:
school records, teachers, guidance counselors, and principals.
Often the particular information that the case manager obtains
depends on which source is contacted. Rarely, is it gathered in a
single report, as medical information might be. In many cases,
the case manager decides what information is needed and
contacts the source or sources most likely to have that
information. For example, a teacher is probably the best source
of information about classroom behavior, whereas school
records provide test scores and indications of past academic
performance. The contact may occur formally (in writing) or
orally (by telephone or personal interview).
Vocational information can be important for several reasons.
People seem to be happiest when their activities are satisfying
and fulfill their needs. There is also the need to earn a living,
and self-support often engenders self-respect. Ways of
gathering vocational information range from asking the client
about his or her work history to arranging for a formal
vocational evaluation. The types of information gathered
include jobs previously held, the ability to get along with co-
workers, work habits (e.g., punctuality and reliability), and
reasons for frequent changes in employment. How much more
information is needed depends on the client’s problem and the
agency’s mission. For example, if the client has no work
experience, then an exploration of vocational interests and
aptitudes may be in order. For the client who has had varied
employment, the focus may shift to attitudes toward work and
the skills developed. The client who has an extensive work
history may need help in reviewing his or her experience and
skills to establish a vocational objective.
Deepening Your Knowledge: Case Study
Let us return to Sharon Bellos’s case, discussed in

60. Chapter One. Sharon’s counselor/case manager
requested a period of vocational evaluation at a regional center
that assesses an individual’s vocational capabilities, interests,
and aptitudes. Sharon and her counselor/case manager, Tom
Chapman, attended staff meeting to hear the vocational
evaluation report. Mr. Chapman later received a written report
(see
Figure 9.7). The report illustrates two important points.
First, information about a client, in this case Sharon, is
integrated with other new information to complete the picture.
In this report, you will read about work history, medical
information, and test scores, as well as the results of the
vocational evaluation. Second, this report is a vocational
evaluation report. Vocational evaluation is a process
of gathering, interpreting, analyzing, and synthesizing all data
about a client that has vocational significance and relating it to
occupational requirements and opportunities.
Figure 9.7Vocational Evaluation Report
Vocational and educational information add other dimensions to
the client record, making the case file more complete. This
information rounds out the case manager’s understanding of
who the client is—strengths, weaknesses, abilities, and
aptitudes.
Discussion Questions
1. In addition to the reports mentioned in this case, what other
reports might Tom require to understand Sharon’s
circumstances and needs?
2. What steps should Tom take to help Sharon prepare for and
understand these assessments?
Author’s Note: We think that it is important for you to review
the chapter you just read. We suggest the following.
· First, re-read the class discussion questions in the text and
answer these as comprehensively as possible.

61. · Second, once you complete the discussion questions, review
the
Chapter Summary, define the
Key Terms, and answer the questions in
Reviewing the Chapter.
· Third, make notes of what stands out for you during your
review. Also, record any questions that you might have.
· Finally, take time to discuss the Questions for Discussion with
another class member, either face-to-face or online. Answering
these questions with a peer will help you solidify the
understanding you have of the contents of the chapter.
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Respond to peers in apa format and at least two refereneces and
a good lengthy paragraph
Peer 1
The results of my workplace environment assessment showed
that my workplace is mildly healthy with a score of 71. This
score is lower
than I thought it would be. To be honest I feel that I work in a
wonderful setting and am very happy there. I believe that the

62. problems lie with the
staff that are unhappy who in turn “bring others down”. It only
takes one person to affect others mood and then the complaining
starts. Once that
person plants a negative seed with others, bad attitudes come
about. To engage in a conversation with someone in the work
environment it is
best to choose the time and place carefully, this will create a
safe space (Clark, 2015).
In my work assessment, the areas that received a lower
score all had to do with management. There is a lack of
communication with the
management as far as decision-making and policies. The
assessment also highlighted the lack of trust among the leaders
in the workplace.
Another area that was a lower number was conflict resolution
skills and addressing disagreements in a responsible manner.
The overall
assessment highlighted that teamwork was a positive factor. The
knowledge that the assessment showed great teamwork means so
much to me
in the place that I work.
I feel that my workplace is civil. I believe that we all
work well together and that we have good management. The
only problem with our
management is that they are not clinical. The management we
have, while they have years of management experience, they
have no medical
knowledge. Not having medical knowledge makes it difficult in
certain situations to get problems addressed. To have a great
leader, you must
have an effective team and a leader who empowers the team,
therefore improving the organization's goals (Broome &
Marshall, 2021). The
kindness and respect are there, but their lack of medical
knowledge can cause frustration among staff. My workplace

63. civil for the most part,
however some people’s personalities do not get along with
others and that can cause frustration.
An example of incivility is when a nurse that I work
with cancelled a surgery for a patient who called do to having a
death in the family. The
problem was that this nurse never spoke to the patient, she
overheard a phone conversation and took it from there. She
cancelled the patient’s
surgery, notified the operating room, and discontinued all the
orders. This caused extreme chaos and the patient’s surgery
was going to be
postponed. She was notified from our boss that what she did
was wrong, and her attitude escalated from that point. She
would never own up to
the fact that she did not actually speak with the patient. The
patient then was called, explanation was given, and placed back
on the surgery
schedule. There were no repercussions for her actions. This
incident caused a great deal of frustration amongst the staff, but
our boss never
reprimanded her for this incident. This same nurse does not pull
her weight and do what is expected of her. This causes turmoil
amongst the rest
of the staff because everyone else must do her work for her.
For a unit to work together as a team there must be
accountability and someone to hold everyone accountable
(Walden University, 2009a).
Unfortunately, in my workplace the accountability is not there
when it needs to be. The example I discussed above is a perfect
example of that.
There are no repercussions for peoples’ actions. A variance is
written about the specific incident which is just a slap on the
wrist and a way to
learn from mistakes. The problem is that the patient is the one
who suffers when people are not held accountable, and I sure

64. hope that changes
sooner then later.
Peer 2
Apparently, my workplace is unhealthy on the healthy
workplace scale with a total of 44/100 (Clark, 2015). It is
possible that we should score lower, but I could not answer the
question regarding how often the organizational culture is
assessed and the one regarding communication at all levels of
the organization is “transparent, direct, and respectful,” so I
answered neutral (4 pts each). I am not in management, so I
would not have any idea whether they are assessing the culture
and how often. In addition, if they were not communicating to
all levels transparently, it is highly unlikely that any of us
would know because, of course, they are not communicating. I
mean, you would not know what someone is not telling you
because they are not telling you. It is broken logic, so only
someone in management could answer that question with
certainty. Overall, I scored 8 questions “untrue” and 5 questions
“somewhat untrue”. The main issue at my workplace has to do
with the separation between management and the staff. There is
an adversarial relationship where there should be cooperation.
The nurses' union and the CNA union are fighting for better
working conditions and better pay, but the hospital management
is denying these requests when negotiating the new contracts.
The fact that management keeps renewing so many agency
contracts at 2 ½ times the pay rate staff nurses receive, but still
refuse an extra $1 per hour raise to staff nurses, causes
resentment to build. I completely understand why the staff feels
unappreciated. On a positive note, the nurses and CNAs work
together well. There is very little confrontation between
personnel and what does arise is resolved quickly. We train new
staff for weeks before they are working on their own and we

65. still provide support to the “newbies” even afterwards. Our
nurse educator is excellent at providing new materials for us to
learn and grow.
With regards to incivility, our organization has had plenty of
incidents. Clark (2015) states, a civil environment means “any
form of bullying, harassment, intimidation, manipulation,
threats, or violence will not be tolerated.” Any nurse who has
ever worked nights has experienced the wonderful interaction
with a private attending physician who does not like getting
calls for orders in the middle of the night. So, the physician put
himself on as the attending. The physician did not place
adequate orders for the patient for prn blood pressure
medication, pain medication, blood sugar control, etc. The
patient has an immediate or emergent need during the night, so
we, as nurses, must call the attending physician for orders. On
occasion, the physician is less than amiable and lashes out at
the nurse usually in an aggressive way. These incidents are
textbook examples of lateral violence in the workplace (Vidal-
Alves, 2021). We, as nurses, remain professional, but even
though complaints have been filed against numerous physicians,
nothing changes, and these incidents still occur. My personal
perspective is ‘if you don’t want to get calls in the middle of
the night, place appropriate prn orders before you leave for the
day or don’t put yourself on as the attending physician.’ Private
physicians continue to put themselves on as the attending
because they get paid more than if the patient has a “house
physician.”