Psychosocial Case Study Format

Resident’s Name: ______

Date of Home Visit: ______

  1. Patient Identification
  2. For confidentiality, write patient’s name and hospital or clinic number, address and phone number on the separate contact form provided, which will be kept separate from the case study.
  3. Initials or pseudonym which will be used to refer to patient throughout case study report
  4. Age
  5. Race/Ethnicity
  6. Gender
  1. Medical History
  2. Chief Complaint or major health problem at this time
  3. HPI
  4. Include current medications at end of HPI
  5. Past Medical History
  6. Family Medical History
  7. Review of Systems
  1. Psychosocial History
  2. Demographic data (Do not need to repeat identifying information stated above)
  3. Marital status and history
  4. Sexual history and preference
  5. Education
  6. Occupational history
  7. Socioeconomic status/financial situation
  8. Is the current illness creating financial distress?
  9. Religious affiliation
  10. Place of birth
  11. Anything unexpected or unique?
  12. Family Genogram and APGAR
  13. Genogram
  14. Draw a genogram including three generations
  15. Include all pertinent information
  16. physical/mental illness
  17. nature of relationships within family
  18. Date of birth
  19. Date and cause of death
  20. Date of marriage/separation/divorce
  21. Occupation
  1. APGAR
  2. To be completed by patient and family members/significant others
  1. Current problems or concerns
  2. What are they?
  3. How distressing are the problems/concerns?
  4. How long has the problems/concerns been occurring?
  5. What strategies has the patient used to cope with/solve the problem?
  6. What is the incentive for change?
  7. Any previous experiences similar to current problem?
  1. Background information
  2. How does the problem fit in the context of the genogram?
  3. If not addressed in the genogram, how does patient relate to others?
  4. Include any experiences that have or continue to have an effect on patient (i.e. enriched or impoverished experiences; traumatic events)
  1. Current life circumstances
  2. How does patient occupy his/her time?
  3. Include current psychosocial stressors, coping strategies, and resources
  4. Habits
  5. eating
  6. drinking
  7. smoking
  8. drugs
  9. caffeine
  10. Diet
  11. Exercise
  12. Romantic/sexual attachments
  13. Close friends/support group
  14. Employment situation
  15. Strengths/areas of improvement
  1. Process Issues
  2. How does patient react to you?
  3. How does patient communicate his/her concerns (e.g. openly, honestly, avoids expressing feelings)?
  4. What is it like to be in the room with patient? What thoughts/emotions are evoked?
  1. Socioeconomic Environment
  2. Past education, occupation, religion, economic status, discipline, and housing while growing up
  3. Current
  4. economic status
  5. housing
  6. transportation
  1. Assessment
  2. Problem list from medical and psychosocial history
  3. Conclusions
  4. Conclusions should be a discussion of your assessment of the psychosocial functioning of patient as well as ways in which it interfaces with his/her organic disease and overall health. If this is not readily derived from the information collected, formulated answers to the following questions will complete this section.
  5. What is patient’s view/model of the world?
  6. What behaviors, excess or deficits, or attitudes does patient have that contribute to or alleviate his/her psychosocial and/or medical problem(s)?
  7. What factors, genetic or environmental, may have contributed to patient’s current problem(s)?
  1. Plan
  2. List some specific suggestions regarding ways in which patient can improve current situation
  3. If patient is smoking, specify “enroll in a smoking cessation program.”
  4. Individual/couple/family therapy?
  5. Support Group?
  6. If nutrition, housing, and/or finances, etc. are problematic, indicate community resources that may be helpful