Assignment Overview:
Social histories are prepared to paint a comprehensive picture of a client's situation and relevant information. This information may come from referral sources, other providers, and the client. For this assignment, you will be drafting a social history for your client, Mr. Brown, from the Case Vignette.
Instructions:
Apply the information provided in the Case Vignette and prepare a social history that addresses the following:
- Client information
- Presenting Problem
- Referral (Including source and reason)
- Medical History
- Personal/Family History
- Education
- Work History
- Personality and Habits
Requirements:
- Submit a Word document that includes a title page.
- Be sure to address each section fully. Each area of information can be broken into sub-sections, listed with the appropriate heading.
- This is a professional report and should use formal language, complete sentences, proper grammar and appropriate sentence structure.
Case Scenario:
Joe Brown (DOB 01/11/1930) is an 85-year-old straight, Black male who was recently admitted to the hospital after his youngest daughter found him lying on the floor in the bathroom. His daughter estimates that he may have been on the ground overnight. Mr. Brown was admitted to the hospital and diagnosed with a right side stroke that left him with moderate weakness in his left arm and leg. Mr. Brown was also diagnosed with dementia.
According to his youngest daughter, Jean, Mr. Brown has been living on his own in a two-story home. He has lived here for 60 years and has been alone for over 2 years after his wife passed away. Mr. Brown has two daughters, Jean, who recently moved in with her father after losing her job, and Catherine who lives 4 hours away with her family. Mr. Brown is a retired school teacher and is described as a private man who does not like having visitors at home.
The hospital social worker got Mr. Brown to agree to shopping assistance and a weekly cleaning service. It is also noted that Mr. Brown has not identified anyone to have power of attorney or any authority to help with finances and bill payments. Jean reports that she and her sister Catherine have a tense relationship that worsened when their mother passed away. The two are currently disagreeing about Mr. Brown's discharge destination and any time it is discussed, Jean and Catherine argue and the conversation ends with no solution. Mr. Brown says he will be fine once he is back in his own home, especially with Jean's support, however, Jean is relutanct to agree to extra services as she knows her father would not want this. Catherine feels that Mr. Brown should transition into an assisted living or nursing facility and is concerned that Jean is not coping well or being realistic.
Mr. Brown's medical history indicates that he has Type II Diabetes and is insulin dependent. He also has been admitted to the hospital on several other occasions recently-twice for a urinary tract infection and once for a fall related to having low blood sugar. Mr. Brown currently needs assistance to get in and out of bed as well as help with his hygiene. However, Mr. Brown is able to walk short distances with a walker
Mr. Brown shares that he receives Social Security benefits as well as retirement pay which is why he does not qualify for support services like food stamps or cash assistance. He gets by each month and is able to maintain his bills. However, Mr. Brown cannot recount how much money is in his accounts or the value of his home. He appeared to be confused by some questions but was generally pleasant and willing to engage in conversation. Mr. Brown says he knows he needs help but is not willing to live in a residential facility.