Tag: Diagnostic

Analyze the objective portion of the note. List additional information that should be included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not?

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not?

Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

What was challenging about writing an intake interview summary?What information is missing that would have made this easier?Identify what questions you would include in order to identify Sue’s

Client Interview

Overview:

After reading about your client, Sue, you will write up an intake summary. Using the

information provided in the Case Vignette, you will take on the role of the case manager

and prepare an intake summary. Additionally, you will identify questions that you would

ask during your interview.

Part 1: Complete an Intake Summary template that includes important

information. Remember that this should be brief and include only the information

that is relevant to eligibility for services.

Your summary will need to include:

The client’s demographic information

Sources of information for the intake interview

Presenting problem

Summary of background and social history related to the problem

Previous contact with your agency

Diagnostic summary statement

Treatment recommendations

Your intake summary will also need to include your name, the date of

contact, and the date of the summary. (Note: best practice suggests

submitting documentation within 48 hours of client contact).

 Part 2:

After completing your intake summary, write a brief summary about the

experience.

What was challenging about writing an intake interview summary?

What information is missing that would have made this easier?

Identify what questions you would include in order to identify Sue’s

strengths. Be sure to use proper APA format and include in-text citations

when discussing specific techniques or questionnaires that you may

suggest.

Client Interview

Requirements:

Part 1: Your intake summary must be submitted using the provided template

attached to the assignment in Blackboard. You will see that the template includes

comments that provide insight and suggestions as to what information should be

included in each section.

Part 2: Complete this part in a separate Word document.

(No cover sheet or reference page)