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{"id":2116,"date":"2020-08-03T21:30:50","date_gmt":"2020-08-03T21:30:50","guid":{"rendered":"https:\/\/nursingwritersbureau.com\/?p=2116"},"modified":"2020-08-03T21:30:50","modified_gmt":"2020-08-03T21:30:50","slug":"genogram-for-client","status":"publish","type":"post","link":"https:\/\/nursingwritersbureau.com\/genogram-for-client\/","title":{"rendered":"GENOGRAM FOR CLIENT"},"content":{"rendered":" Prepare A Genogram For The Client You Selected. The Genogram Should Extend Back By At Least Three Generations (Great Grandparents, Grandparents, And Parents)<\/p>\n
I will provide a client without violating HIPPA these are the areas need to be addressed in the genogram Demographic information Presenting problem History or present illness Past psychiatric history Medical history Substance use history Developmental history Family psychiatric history Psychosocial history History of abuse\/trauma Review of systems Physical assessment Mental status exam Differential diagnosis Case formulation Treatment plan<\/p>\n
Pain Today (0-10): Pain is described as 1 out of 10. Allergies: NKDA SLEEP ISSUES: Hours of sleep per night: 6-7 Snores: No Sleep latency: 0-15 min Daytime Somnolence: No Substance History: Caffeine Use: No Cups\/Date Equivalent: Tobacco\/e-cigs: none Packs\/Date Equivalent: Illicit drug use: denied DEVELOPMENTAL\/SOCIAL HISTORY: Patient reports that he grew up in Mississippi. His father died in a motor vehicle accident when he was several months old. Raised by his mother and stepfather. Denies any abuse history. Never married. Has a bachelor\u2019s of arts in communication from Grambling UNIV. reports that he worked at Lowe\u2019s during college and thereafter. Is an AGR Soldier within the United States Army reserves in Mississippi from 2012-2018. States that his religion and spiritual values preference being Christian. Patient was primarily raised by Biological parents and that childhood was generally Good. Patient denies ever being physically, sexually or emotionally abused. Highest level of education achieved is: 4-year college degree or equivalent. Patient is currently single and currently lives with Other. Housing is currently Off-Post. Patient reports religion, faith or spirituality DO play an important role in life. Social support reported as satisfactory. Patient reports the following history of legal issues: None of the above. PAST FAMILY\/MEDICAL HISTORY: Family Medical Illnesses: None Family Behavioral Health Illnesses: None Family Substance Use History: None OBJECTIVE MSE Orientation: \u2610None \u2612Place \u2612Object \u2612Person \u2612Time Attention: \u2612Normal \u2610Distracted \u2612Other: Maintained focus and attention throughout the session. Appearance: \u2612Neat \u2610Disheveled \u2610Inappropriate \u2610Bizarre \u2612Other: dressed in civilian attire. Behavior: \u2612Cooperative \u2610Guarded \u2610Withdrawn \u2610Agitated \u2610Stereotyped \u2610Aggressive \u2612Other: calm Eye Contact: \u2612Normal \u2610Intense \u2610Limited \u2612Other: maintained appropriate eye contact during the session. Psychomotor: \u2612Normal \u2610Restless \u2610Tics \u2610Slowed \u2610Other Speech: \u2612Normal rate, volume, and rhythm \u2610Tangential \u2610Pressured \u2610Impoverished \u2610Other Mood: \u201cI feel good overall.\u201d Affect: \u2612Congruent with mood \u2612Euthymic \u2610Anxious \u2610Angry \u2610Depressed \u2610Euphoric \u2610Irritable \u2610Constricted \u2610Flat \u2610Labile \u2610Other Thought Process: \u2612WNL \u2610Circumstantial \u2610Tangential \u2610Loose Associations \u2610Disorganized \u2610Other Thought Content: \u2612WNL \u2610SI \u2610HI \u2612 potentially paranoid \u2610A\/V hallucinations \u2610Delusional \u2612Other: Denies SI\/HI plan or intent Memory Impairment: \u2612WNL \u2610Short-Term \u2610Long-Term \u2610Other Insight: \u2610Good \u2612Fair \u2610Poor Comments: Judgment: \u2610Good \u2612Fair \u2610Poor Comments: BHDP: Behavioral Health Vitals (patient reported): Overall health reported as: Good Pain Level (0-10): 0 Currently treated: N\/A Suicidal Ideation Risk – C-SSRS-S score: 0 Past\/Prep Behavior last 3 months: N\/A # past attempts as of 12\/07\/2016: 2 Most recent Suicidal Ideation: N\/A Suicidal Ideation Duration: N\/A Suicidal Ideation Frequency: N\/A Protective Elements Stopping Suicidal Actions: Faith\/Religion, Family, Hope for future, Friends, Other Harm Others Risk over next week as of 12\/18\/2018 – None Active Plan: N\/A Patient with access to weapons: No Recent Outcome Measures (last 30 days) BASIS24 – Score: 0.56 – Subclinical to low level of general distress reported (12\/18\/2018) PHQ9 – Score: 4 – Depressive syndrome unlikely (12\/18\/2018) GAD7 – Score: 3 – Anxiety syndrome unlikely (12\/18\/2018) PCL-5 – Score: 3 – None-Low PTSD symptoms reported (12\/18\/2018) PCL-C: N\/A AUDIT: N\/A CSI – Score: 8 – Possible relationship distress reported. Evaluation indicated. (11\/30\/2018) ISI – Score: 9 – Subthreshold insomnia (12\/18\/2018) BAM: N\/A LABORATORY RESULTS: Reviewed laboratory results ASSESSMENT Patient Strengths: \u2610 None reported \u2610 motivated \u2610 insightful \u2610 committed \u2610 Tx compliant \u2612 family support \u2610 social support \u2610desires change \u2610 previous positive BH experience \u2610 desire to address longstanding issues \u2612 good expressive language \u2610 good ego strength \u2610 Other: Patient Barriers: \u2610 None reported \u2610 unmotivated \u2610 limited insight \u2612 uncommitted \u2610 Tx non-compliant \u2610 limited family support: \u2610resistant \u2610co-morbid Dx \u2610 previous negative BH experience \u2612 limited social support \u2610cognitive impairment\/TBI \u2610low ego strength \u2612 Other: Not resistant but questions the validity of his behavioral healthcare SAFETY RISK ASSESSMENT \u2610YES \u2612NO History of Suicidal Ideation: \u2610YES \u2612NO History of Suicidal Planning: \u2610YES \u2612NO History of Suicidal Gestures: \u2610YES \u2612NO History of Suicidal Attempts: \u2610YES \u2612NO Close friends\/family who have attempted\/completed suicide: \u2610YES \u2612NO History of intentionally harming others or destroying property: \u2610YES \u2612NO Current intentions to engage in above behaviors: \u2610YES \u2612NO History of impulsive-taking: Risk Factors: \u2610None reported \u2612Male \u2610Impulsive \u2612Weapons access \u2610Legal Stressors \u2610Financial Stressors \u2612Occupational conflict \u2610Chronic medical problems \u2610Substance abuse: \u2610Abuse victim: \u2610History of suicidal gestures \u2610History of family\/friend suicide \u2610Relationship problems \u2610OTHER: insomnia Protective Factors: \u2610None reported \u2610Married \u2610Children \u2612Positive religious coping \u2612Future orientation \u2612Healthy coping skills \u2610Active treatment participation \u2612Supportive spouse \u2610Supportive family \u2610Social support \u2612PT wants to continue treatment \u2610OTHER: This provider considered the above risk\/protective factors and has determined the following risk level: RISK: Harm to Self \u2013 \u2612Not Elevated \u2610Low \u2610Intermediate \u2610High Harm to Others \u2013 \u2612Not Elevated \u2610Low \u2610Intermediate \u2610High SAFETY:\u2610YES \u2612NO Imminent threat to self. \u2610YES \u2612NO Imminent threat to others. \u2610YES \u2612NO Imminent threat of harm from other individuals. \u2612YES \u2610NO Patient is fully able to make informed medical decisions and manage affairs. \u2612YES \u2610NO Patient is unlikely to withhold information about SI\/HI ideation or intent. \u2612YES \u2610NO Patient is considered to be a reliable source of information. DIAGNOSTIC FORMULATION: This is a 35-year-old male who was deployed to the Middle East as an individual unit augmentee. He reports that he became an conflict with his leadership over mishandling funds, and other ethical related issues. The unit is making the claim that the patient is misperceiving these incidences, based off of the provider assessment in-theater; paranoia over this situation was identified. DSM Diagnosis(es) Code: Other occupational structure stressors R\/O: Delusional Disorder, psychosis Estimated Treatment Prognosis: Good . PLAN Treatment Summary: 1) Patient was provided psychoeducation, assessment of current functioning, risk\/safety assessment, development of rapport, development of treatment goals, empathic listening and directed questioning techniques to elicit information and provided supportive environment to facilitate patient insight. Patient was provided active listening, strategic reflection, encouragement and validation. Other therapies discussed include: 1. Diaphragmatic Breathing 2. Progressive Muscle Relaxation 3. Safe Place Imagery 4. Mindful breathing 5. Problem solving techniques 6. Sleep Hygiene 7. Discussed, Virtual Hope box, Tactical Breather, Moving forward and Mindfulness coach apps available on smart phone. 2) Discussed open-access clinic available at BH clinic. Pt agree if symptoms worsen or if new behavioral concerns arise, Pt to call, RTC, or if after duty hours, go to ED and\/or call emergency line. Limits to confidentiality were discussed with the patient as appropriate. 3) Attending behavioral health group for deployed service members on Monday, Tuesday, Thursday and\/or Friday from 1430-1600. Medications: None Risk\/Suicide Management Plan: \u2612YES \u2610N\/A The patient will follow-up in therapy to address treatment goals. \u2612YES \u2610N\/A The patient has demonstrated the ability to and has agreed to make use of a crisis response plan. \u2610YES \u2612N\/A The patient was added to the High Interest Program to track continuity of care. \u2610YES \u2612N\/A Persons notified: \u2610YES \u2612N\/A Emergency Contacts: \u2612YES \u2610N\/A Emergency Contacts and Crisis Response Plan: Call friends, family members, or a trusted chaplain. Contact Military One Source at http:\/\/www.militaryonesource.mil\/ or call 00-800-3429-6477. Call Wounded Soldier and Family Hotline at OCONUS DSN 312-421-3700. Access www.realwarriors.net\/livechat for online chat support. After duty hours, call 112, call MPs, First Sergeant or primary supervisor if feeling suicidal. During duty hours, walk in to Behavioral Health Clinic. Go to the Emergency Room at Landstuhl Regional Medical Center. They will call the on-call Behavioral Health Provider. \u2610YES \u2612N\/A Safety plan worksheet uploaded into HAIMS. <\/p>\n \n
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