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Case Presentation including the Problem Oriented Method: DRAFT

1. Reason for Case Presentation (Specific clinical question or problem? Lack of progress? Learningopportunity? Differential Diagnosis?)

2. Identifying Information- Demographic Info.: Age, Gender, Ethnicity, Religion, Marital Status,Education, Occupation, Household Members. Initial Contact: Self referral or other. Presentingproblem.

3. Background Information- Baseline.4. Problem #1 Title and Explanation5. Subjective Information

a. History of the problem. HPI (History of the Present Illness) including attempts atresolution. Why Now? Precipitant? Motivation (What do they want to be different and

how strongly)?

b.c. Safety Issues (SI -Suicidal Ideation, HI -Homicidal Ideation, psychosis, SIB self injurious

behaviors)d. Medications: all current meds (details - name, dosage, start date, compliance, benefit,

prescriber). Any concerns about meds. Hx of psychotropic meds.

e. Medical History: accs, ills, surgs, allergies (to meds). Details on current conditions.f. Family History: FOO, medical Hx, deceased/cause, MH/SA Hx.g. Clients MH/SA History: previous treatment exps. (Why? Who? Where? When? How

helpful?). Details of SA issues: substance, age of first use, frequency of use, amount

used, how long used, LDU. Related Problems: rels, legal, med, financial, regrets?

h. Developmental History/ Sexual and Relationship History: Abuse issues (phys, sexual,emotional) and trauma; milestones; significant losses; orientation?

i. Religious/ Spirituality: belief system, affiliations and commitments.j. Social Environment: Living Situation, Family/Friend Rels; Support Networks.k. Educational: Current/History/Aspirationsl. Occupational: Current/ History/Aspirationsm. Legal : Current/ History/Pendingn. Militaryo. Hobbies/areas of interestp. Self-identified Strengths and Weaknessesq. Expectations for Treatment.

6. Objective Informationa. Observations by the counselorb. information based on records from other professionals

7. DSM IV Diagnosis 5 AxesA. Axis 1a, Axis 1b, Axis 1cB. Axis 2.C. Axis 3.D. Axis 4.

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E. Axis 5.F. What specific criteria (symptoms and characteristics) support the diagnoses on Axis

1 and Axis 2?

8. Counselor's Conceptualization of the ProblemA. Use hypotheses from the 28 Core Clinical Hypotheses.B. Give an explanation of the application of the hypothesis to the client, based on

specific data.

C. Give a probe or way to test the hypothesis to confirm or disconfirm it.9. Treatment Plan Goals:

A. Measurable quantifiable and verifiable.B. Realistic progression, not perfectionC. Achievable not dependent upon uncontrollable events or others decisions.

10.Assessment of Progress / RevisionA. Details of Progress or Lack thereofB. Barriers to achieving goalsC. What else needs to be done to overcome the barriers?