Accurate reflection of the client engagement and how to improve your interaction when working with...

Question

Accurate reflection of the client engagement and how to improve your interaction when working with this client again

·Written in a SOAP or similar format (case notes)

·Containing relevant information to the case, client and case plan

· Also a writtenreflection on actions to improve your interaction with future clients and case management skills and include two (2) references supporting this reflection.

Azra S · Accepted Answer

Name of Patient: Vince
Subjective
Voices telling him he is a bad person; doesn’t deserve to live. Will not be going to the hospital again.
Objective
Presenting Problem: Paranoid Schizophrenia, Suicidal Tendencies
Psychotic symptoms: 
· Auditory Hallucinations
Delusions:
· People talking about him
Assesment
· Appears extremely anxious, pacing around
· Distressed
· Suicidal, pile of pills on table
· Paranoia episode
Plan
Building a personalized safety plan for Vince for any possible suicidal attempts in future.
Previous Suicidal behavior/s
· Several
· Overdose
Triggers
· Hallucinations
· Social Activity 
· Shopping visits
What can help
 Psychosocial Interventions:
1) Cognitive Behavioral Therapy
· Assessment
· Normalization – reduces harmful effects of paranoia
· Socratic questioning
· ABC model – for organizing thoughts; explaining link between emotions and beliefs and identifying triggers.
· Developing problem solving skills.
2) Family support 
· Multi-family workshops / Movie nights with family 
· Help build trust
· Encouragement 
· Sense of connection.

Accurate reflection of the client engagement and how to improve your interaction when working with this client again ·Written in a SOAP or similar format (case notes) ·Containing relevant information...

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