sample case study social work

Social Work Practice with Carers

Case Study 2: Josef

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Josef is 16 and lives with his mother, Dorota, who was diagnosed with Bipolar disorder seven years ago. Josef was born in England. His parents are Polish and his father sees him infrequently.

This case study looks at the impact of caring for someone with a mental health problem and of being a young carer , in particular the impact on education and future employment .

When you have looked at the materials for the case study and considered these topics, you can use the critical reflection tool and the action planning tool to consider your own practice.

• One-page profile

Support plan

Transcript (.pdf, 48KB)

Name : Josef Mazur

Gender : Male

Ethnicity : White European

Download resource as a PDF file

First language : English/ Polish

Religion : Roman Catholic

Josef lives in a small town with his mother Dorota who is 39. Dorota was diagnosed with Bi-polar disorder seven years ago after she was admitted to hospital. She is currently unable to work. Josef’s father, Stefan, lives in the same town and he sees him every few weeks. Josef was born in England. His parents are Polish and he speaks Polish at home.

Josef is doing a foundation art course at college. Dorota is quite isolated because she often finds it difficult to leave the house. Dorota takes medication and had regular visits from the Community Psychiatric Nurse when she was diagnosed and support from the Community Mental Health team to sort out her finances. Josef does the shopping and collects prescriptions. He also helps with letters and forms because Dorota doesn’t understand all the English. Dorota gets worried when Josef is out. When Dorota is feeling depressed, Josef stays at home with her. When Dorota is heading for a high, she tries to take Josef to do ‘exciting stuff’ as she calls it. She also spends a lot of money and is very restless.

Josef worries about his mother’s moods. He is worried about her not being happy and concerned at the money she spends when she is in a high mood state. Josef struggles to manage his day around his mother’s demands and to sleep when she is high. Josef has not told anyone about the support he gives to his mother. He is embarrassed by some of the things she does and is teased by his friends, and he does not think of himself as a carer. Josef has recently had trouble keeping up with course work and attendance. He has been invited to a meeting with his tutor to formally review attendance and is worried he will get kicked out. Josef has some friends but he doesn’t have anyone he can confide in. His father doesn’t speak to his mother.

Josef sees some information on line about having a parent with a mental health problem. He sends a contact form to ask for information. Someone rings him and he agrees to come into the young carers’ team and talk to the social worker. You have completed the assessment form with Josef in his words and then done a support plan with him.

Back to Summary

Josef Mazur

What others like and admire about me

Good at football

Finished Arkham Asylum on expert level

What is important to me

Mum being well and happy

Seeing my dad

Being an artist

Seeing my friends

How best to support me

Tell me how to help mum better

Don’t talk down to me

Talk to me 1 to 1

Let me know who to contact if I am worried about something

Work out how I can have some time on my own so I can do my college work and see my friends

Don’t tell mum and my friends

Date chronology completed : 7 March 2016

Date chronology shared with person: 7 March 2016

Young Carers Assessment

Do you look after or care for someone at home?

The questions in this paper are designed to help you think about your caring role and what support you might need to make your life a little easier or help you make time for more fun stuff.

Please feel free to make notes, draw pictures or use the form however is best for you.

What will happen to this booklet?

This is your booklet and it is your way to tell an adult who you trust about your caring at home. This will help you and the adult find ways to make your life and your caring role easier.

The adult who works with you on your booklet might be able to help you with everything you need. If they can’t, they might know other people who can.

Our Agreement

• I will share this booklet with people if I think they can help you or your family
• I will let you know who I share this with, unless I am worried about your safety, about crime or cannot contact you
• Only I or someone from my team will share this booklet
• I will make sure this booklet is stored securely
• Some details from this booklet might be used for monitoring purposes, which is how we check that we are working with everyone we should be

Signed: ___________________________________

Young person:

• I know that this booklet might get shared with other people who can help me and my family so that I don’t have to explain it all over again
• I understand what my worker will do with this booklet and the information in it (written above).

Signed: ____________________________________

Name :             Josef Mazur Address :       1 Green Avenue, Churchville, ZZ1 Z11 Telephone:        012345 123456 Email:            [email protected] Gender :         Male Date of birth :        11.11.1999        Age: 16 School :            Green College, Churchville Ethnicity :        White European First language :        English/ Polish Religion :         Baptised Roman Catholic GP :            Dr Amp, Hill Surgery

The best way to get in touch with me is:

Do you need any support with communication?

*Josef is bilingual – English and Polish. He speaks English at school and with his friends, and Polish at home. Josef was happy to have this assessment in English, however, another time he may want to have a Polish interpreter. It will be important to ensure that Josef is able to use the words he feels best express himself.

About the person/ people I care for

I look after my mum who has bipolar disorder. Mum doesn’t work and doesn’t really leave the house unless she is heading for a high. When Mum is sad she just stays at home. When she is getting hyper then she wants to do exciting stuff and she spends lots of money and she doesn’t sleep.

Do you wish you knew more about their illness?

Do you live with the person you care for?

What I do as a carer It depends on if my mum has a bad day or not. When she is depressed she likes me to stay home with her and when she is getting hyper then she wants me to go out with her. If she has new meds then I like to be around. Mum doesn’t understand English very well (she is from Poland) so I do all the letters. I help out at home and help her with getting her medication.

Tell us what an average week is like for you, what kind of things do you usually do?

Monday to Friday

Get up, get breakfast, make sure mum has her pills, tell her to get up and remind her if she’s got something to do.

If mum hasn’t been to bed then encourage her to sleep a bit and set an alarm

College – keep phone on in case mum needs to call – she usually does to ask me to get something or check when I’m coming home

Go home – go to shops on the way

Remind mum about tablets, make tea and pudding for both of us as well as cleaning the house and fitting tea in-between, ironing, hoovering, hanging out and bringing in washing

Do college work when mum goes to bed if not too tired

More chores

Do proper shop

Get prescription

See my friends, do college work

Sunday – do paper round

Physical things I do….

(for example cooking, cleaning, medication, shopping, dressing, lifting, carrying, caring in the night, making doctors appointments, bathing, paying bills, caring for brothers & sisters)

I do all the housework and shopping and cooking and get medication

Things I find difficult

Emotional support I provide…. (please tell us about the things you do to support the person you care for with their feelings; this might include, reassuring them, stopping them from getting angry, looking after them if they have been drinking alcohol or taking drugs, keeping an eye on them, helping them to relax)

If mum is stressed I stay with her

If mum is depressed I have to keep things calm and try to lighten the mood

She likes me to be around

When mum is heading for a high wants to go to theme parks or book holidays and we can’t afford it

I worry that mum might end up in hospital again

Mum gets cross if I go out

Other support

Please tell us about any other support the person you care for already has in place like a doctor or nurse, or other family or friends.

The GP sees mum sometimes. She has a nurse who she can call if things get bad.

Mum’s medication comes from Morrison’s pharmacy.

Dad lives nearby but he doesn’t talk to mum.

Mum doesn’t really have any friends.

Do you ever have to stop the person you care for from trying to harm themselves or others?

Some things I need help with

Sorting out bills and having more time for myself

I would like mum to have more support and to have some friends and things to do

On a normal week, what are the best bits? What do you enjoy the most? (eg, seeing friends, playing sports, your favourite lessons at school)

Seeing friends

When mum is up and smiling

Playing football

On a normal week, what are the worst bits? What do you enjoy the least? (eg cleaning up, particular lessons at school, things you find boring or upsetting)

Nagging mum to get up

Reading letters

Missing class

Mum shouting

Friends laugh because I have to go home but they don’t have to do anything

What things do you like to do in your spare time?

Do you feel you have enough time to spend with your friends or family doing things you enjoy, most weeks?

Do you have enough time for yourself to do the things you enjoy, most weeks?  (for example, spending time with friends, hobbies, sports)

Are there things that you would like to do, but can’t because of your role as a carer?

Can you say what some of these things are?

See friends after college

Go out at the weekend

Time to myself at home

It can feel a bit lonely

I’d like my mum to be like a normal mum

School/ College Do you think being your caring role makes school/college more difficult for you in any way?

If you ticked YES, please tell us what things are made difficult and what things might help you.

Things I find difficult at school/ college

Sometimes I get stressed about college and end up doing college work really late at night – I get a bit angry when I’m stressed

I don’t get all my college work done and I miss days

I am tired a lot of the time

Things I need help with…

I am really worried they will kick me out because I am behind and I miss class. I have to meet my tutor about it.

Do your teachers know about your caring role?

Are you happy for your teachers and other staff at school/college to know about your caring role?

Do you think that being a carer will make it more difficult for you to find or keep a job?

Why do you think being a carer is/ will make finding a job more difficult?

I haven’t thought about it. I don’t know if I’ll be able to finish my course and do art and then I won’t be able to be an artist.

Who will look after mum?

What would make it easier for you to find a job after school/college?

Finishing my course

Mum being ok

How I feel about life…

Do you feel confident both in school and outside of school?

Somewhere in the middle

In your life in general, how happy do you feel?

Quite unhappy

In your life in general, how safe do you feel?

How healthy do you feel at the moment?

Quite healthy

Being heard

Do you think people listen to what you are saying and how you are feeling?

If you said no, can you tell us who you feel isn’t listening or understanding you sometimes   (eg, you parents, your teachers, your friends, professionals)

I haven’t told anyone

I can’t talk to mum

My friends laugh at me because I don’t go out

Do you think you are included in important decisions about you and your life? (eg, where you live, where you go to school etc)

Do you think that you’re free to make your own choices about what you do and who you spend your time with?

Not often enough

Is there anybody who knows about the caring you’re doing at the moment?

If so, who?

I told dad but he can’t do anything

Would you like someone to talk to?

Supporting me Some things that would make my life easier, help me with my caring or make me feel better

I don’t know

Fix mum’s brain

People to help me if I’m worried and they can do something about it

Not getting kicked out of college

Free time – time on my own to calm down and do work or have time to myself

Time to go out with my friends

Get some friends for mum

I don’t want my mum to get into trouble

Who can I turn to for advice or support?

I would like to be able to talk to someone without mum or friends knowing

Would you like a break from your caring role?

How easy is it to see a Doctor if you need to?

To be used by social care assessors to consider and record measures which can be taken to assist the carer with their caring role to reduce the significant impact of any needs. This should include networks of support, community services and the persons own strengths. To be eligible the carer must have significant difficulty achieving 1 or more outcomes without support; it is the assessors’ professional judgement that unless this need is met there will be a significant impact on the carer’s wellbeing. Social care funding will only be made available to meet eligible outcomes that cannot be met in any other way, i.e. social care funding is only available to meet unmet eligible needs.

Date assessment completed :            7 March 2016

Social care assessor conclusion

Josef provides daily support to his mum, Dorota, who was diagnosed with bipolar disorder seven years ago. Josef helps Dorota with managing correspondence, medication and all household tasks including shopping. When Dorota has a low mood, Josef provides support and encouragement to get up. When Dorota has a high mood, Josef helps to calm her and prevent her spending lots of money. Josef reports that Dorota has some input from community health services but there is no other support. Josef’s dad is not involved though Josef sees him sometimes, and there are no friends who can support Dorota.

Josef is a great support to his mum and is a loving son. He wants to make sure his mum is ok. However, caring for his mum is impacting: on Josef’s health because he is tired and stressed; on his emotional wellbeing as he can get angry and anxious; on his relationship with his mother and his friends; and on his education. Josef is at risk of leaving college. Josef wants to be able to support his mum better. He also needs time for himself, to develop and to relax, and to plan his future.

Eligibility decision :                Eligible for support

What’s happening next :            Create support plan

Completed by Name : Role : Organisation :

Name: Josef Mazur

Address 1 Green Avenue, Churchville, ZZ1 Z11

Telephone 012345 123456

Email [email protected]

Gender: Male

Date of birth: 11.11.1999 Age: 16

School Green College, Churchville

Ethnicity White European

First language English/ Polish

Religion Baptised Roman Catholic

GP Dr Amp, Hill Surgery

My relationship to this person son

Name Dorota Mazur

Gender Female

Date of birth 12.6.79 Age 36

First language Polish

Religion Roman Catholic

Support plan completed by

Organisation

Date of support plan: 7 March 2016

This plan will be reviewed on: 7 September 2016

Signing this form

Please ensure you read the statement below in bold, then sign and date the form.

I understand that completing this form will lead to a computer record being made which will be treated confidentially. The council will hold this information for the purpose of providing information, advice and support to meet my needs. To be able to do this the information may be shared with relevant NHS Agencies and providers of carers’ services. This will also help reduce the number of times I am asked for the same information.

If I have given details about someone else, I will make sure that they know about this.

I understand that the information I provide on this form will only be shared as allowed by the Data Protection Act.

Josef has given consent to share this support plan with the CPN but does not want it to be shared with his mum.

Mental health

The social work role with carers in adult mental health services has been described as: intervening and showing professional leadership and skill in situations characterised by high levels of social, family and interpersonal complexity, risk and ambiguity (Allen 2014). Social work with carers of people with mental health needs, is dependent on good practice with the Mental Capacity Act where practitioner knowledge and understanding has been found to be variable (Iliffe et al 2015).

• Carers Trust (2015) Mental Health Act 1983 – Revised Code of Practice Briefing
• Carers Trust (2013) The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care in England
• Mind, Talking about mental health
• Tool 1: Triangle of care: self-assessment for mental health professionals – Carers Trust (2013) The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care in England Second Edition (page 23 Self-assessment tool for organisations)

Mental capacity, confidentiality and consent

Social work with carers of people with mental health needs, is dependent on good practice with the Mental Capacity Act where practitioner knowledge and understanding has been found to be variable (Iliffe et al 2015). Research highlights important issues about involvement, consent and confidentiality in working with carers (RiPfA 2016, SCIE 2015, Mental Welfare Commission for Scotland 2013).

• Beddow, A., Cooper, M., Morriss, L., (2015) A CPD curriculum guide for social workers on the application of the Mental Capacity Act 2005 . Department of Health
• Bogg, D. and Chamberlain, S. (2015) Mental Capacity Act 2005 in Practice Learning Materials for Adult Social Workers . Department of Health
• Department of Health (2015) Best Interest Assessor Capabilities , The College of Social Work
• RiPfA Good Decision Making Practitioner Handbook
• SCIE Mental Capacity Act resource  
• Tool 2: Making good decisions, capacity tool (page 70-71 in good decision making handbook)

Young carers

A young carer is defined as a person under 18 who provides or intends to provide care for another person. The concept of care includes practical or emotional support. It is the case that this definition excludes children providing care as part of contracted work or as voluntary work. However, the local authority can ignore this and carry out a young carer’s need assessment if they think it would be appropriate. Young carers, young adult carers and their families now have stronger rights to be identified, offered information, receive an assessment and be supported using a whole-family approach (Carers Trust 2015).

• SCIE (2015) Young carer transition in practice under the Care Act 2014
• SCIE (2015) Care Act: Transition from children’s to adult services – early and comprehensive identification
• Carers Trust (2015) Rights for young carers and young adult carers in the Children and Families Act
• Carers Trust (2015) Know your Rights: Support for Young Carers and Young Adult Carers in England
• The Children’s Society (2015) Hidden from view: The experiences of young carers in England  
• DfE (2011) Improving support for young carers – family focused approaches
• ADASS and ADCS (2015) No wrong doors: working together to support young carers and their families
• Carers Trust, Supporting Young Carers and their Families: Examples of Practice
• Refugee toolkit webpage: Children and informal interpreting
• SCIE (2010) Supporting carers: the cared for person
• SCIE (2015) Care Act Transition from children’s to adults’ services – Video diaries
• Tool 3: Young carers’ rights – The Children’s Society (2014) The Know Your Rights pack for young carers in England!
• Tool 4: Vision and principles for adults’ and children’s services to work together

Young carers of parents with mental health problems

The Care Act places a duty on local authorities to assess young carers before they turn 18, so that they have the information they need to plan for their future. This is referred to as a transition assessment. Guidance, advocating a whole family approach, is available to social workers (LGA 2015, SCIE 2015, ADASS/ADCS 2011).

• SCIE (2012) At a glance 55: Think child, think parent, think family: Putting it into practice
• SCIE (2008) Research briefing 24: Experiences of children and young people caring for a parent with a mental health problem
• SCIE (2008) SCIE Research briefing 29: Black and minority ethnic parents with mental health problems and their children
• Carers Trust (2015) The Triangle of Care for Young Carers and Young Adult Carers: A Guide for Mental Health Professionals
• ADASS and ADCS (2011) Working together to improve outcomes for young carers in families affected by enduring parental mental illness or substance misuse
• Ofsted (2013) What about the children? Joint working between adult and children’s services when parents or carers have mental ill health and/or drug and alcohol problems
• Mental health foundation (2010) MyCare The challenges facing young carers of parents with a severe mental illness
• Children’s Commissioner (2012) Silent voices: supporting children and young people affected by parental alcohol misuse
• SCIE, Parental mental health and child welfare – a young person’s story

Tool 5: Family model for assessment

• Tool 6: Engaging young carers of parents with mental health problems or substance misuse

Young carers and education/ employment

Transition moments are highlighted in the research across the life course (Blythe 2010, Grant et al 2010). Complex transitions required smooth transfers, adequate support and dedicated professionals (Petch 2010). Understanding transition theory remains essential in social work practice (Crawford and Walker 2010). Partnership building expertise used by practitioners was seen as particular pertinent to transition for a young carer (Heyman 2013).

• TLAP (2013) Making it real for young carers
• Learning and Work Institute (2018) Barriers to employment for young adult carers
• Carers Trust (2014) Young Adult Carers at College and University
• Carers Trust (2013) Young Adult Carers at School: Experiences and Perceptions of Caring and Education
• Carers Trust (2014) Young Adult Carers and Employment
• Family Action (2012) BE BOTHERED! Making Education Count for Young Carers

Download The Triangle of Care as a PDF file

The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care in England

The Triangle of Care is a therapeutic alliance between service user, staff member and carer that promotes safety, supports recovery and sustains wellbeing…

Download the Capacity Tool as a PDF file

Capacity Tool Good decision-making Practitioners’ Handbook

The Capacity tool on page 71 has been developed to take into account the lessons from research and the case CC v KK. In particular:

• that capacity assessors often do not clearly present the available options (especially those they find undesirable) to the person being assessed
• that capacity assessors often do not explore and enable a person’s own understanding and perception of the risks and advantages of different options
• that capacity assessors often do not reflect upon the extent to which their ‘protection imperative’ has influenced an assessment, which may lead them to conclude that a person’s tolerance of risks is evidence of incapacity.

The tool allows you to follow steps to ensure you support people as far as possible to make their own decisions and that you record what you have done.

Download Know your rights as a PDF file

Tool 3: Know Your Rights Young Carers in Focus

This pack aims to make you aware of your rights – your human rights, your legal rights, and your rights to access things like benefits, support and advice.

Need to know where to find things out in a hurry? Our pack has lots of links to useful and interesting resources that can help you – and help raise awareness  about young carers’ issues!

Know Your Rights has been produced by Young Carers in Focus (YCiF), and funded by the Big Lottery Fund.

Tool 4: Vision and principles for adults’ and children’s services to work together to support young carers

Download the tool   as a PDF file

You can use this tool to consider how well adults’ and children’s services work together, and how to improve this.

Click on the diagram to open full size in a new window

This is based on ADASS and ADCS (2015) No wrong doors : working together to support young carers and their families

Download the tool as a PDF file

You can use this tool to help you consider the whole family in an assessment or review.

What are the risk, stressors and vulnerability factors?

How is the child/ young person’s wellbeing affected?

How is the adult’s wellbeing affected?

What are the protective factors and available resources?

This tool is based on SCIE (2009) Think child, think parent, think family: a guide to parental mental health and child welfare

Tool 6: Engaging young carers

Young carers have told us these ten things are important. So we will do them.

• Introduce yourself. Tell us who you are and what your job is.
• Give us as much information as you can.
• Tell us what is wrong with our parents.
• Tell us what is going to happen next.
• Talk to us and listen to us. Remember it is not hard to speak to us we are not aliens.
• Ask us what we know and what we think. We live with our parents; we know how they have been behaving.
• Tell us it is not our fault. We can feel guilty if our mum or dad is ill. We need to know we are not to blame.
• Please don’t ignore us. Remember we are part of the family and we live there too.
• Keep on talking to us and keeping us informed. We need to know what is happening.
• Tell us if there is anyone we can talk to. Maybe it could be you.

• Equal opportunities
• Complaints procedure
• Terms and conditions
• Privacy policy
• Cookie policy
• Accessibility

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• May 5, 2022
• 19 min read

Definition, importance, information included, presentation, amending, legislation, terminating client, sharing with client, templates: SOAP, DAP, BIRP, BPSS, Intake report

Three sections follow:

1. Background Material that provides the context for the topic

2. A suggested Practice Approach

3. A list of Supporting Material / References

Feedback welcome!

Background Material

What are case notes?

Sommers-Flanagan (2009) suggest case notes reflect the information provided at an interview and usually cover the following three broad areas:

Identifying, evaluating, and exploring the client's chief complaint and associated therapy goals.

Obtaining data related to the client's interpersonal style, interpersonal skills, and personal history.

Evaluating the client's current life situation and functioning.

AASW (2016) add a fourth point: case notes should also include actions to be taken with regard to the client. Lillis (2017) elaborates: case notes could include reference to or inclusion of other documents, e.g. a care plan, a purchase order and a review summary. For Lillis, case notes are a combination of documents that successfully describe the situation, needs and actual services provided.

Why are case notes important?

Case notes have been emphasized as central to the work in which social workers engage. Case notes:

help focus work,

support effective partnerships with service users and carers,

provide a comprehensive, documented account of work with service users and their families,

assist continuity when workers change,

provide an essential tool for managers to monitor work,

can becomes a major source of evidence for investigations and enquiries.

Inadequate case records result in poor decision-making and adverse client outcomes (AASW, 2016; Lillis, 2017).

Healy and Mulholland (2007) expand many of the above points as follows. Case records are:

a vital information base for client work

formal and factual information—what the case consists of, what has been done to deal with it, when the case began, when the situation changed, the service modifications that took place, when the case ended and the final outcome

situational data on the client’s needs (phone calls, notes, emails, face-to-face interviews)

a way of clarifying the case situation for both the practice worker and the client

having the client speak, and the subsequent work presenting the case in a coherent and focused written form helps clarify the complex issues of the case for both worker and client

a means by which social workers and service users can make visible to others, such as team members, aspects of the social context of the client’s needs that might otherwise be ignored

recording case notes provides a focused social work coherence to them, frames the individuality of the client’s situation, and makes it easier for others dealing with the client to understand the situation

a method of promoting opportunities for collaborative responses in health and community services teams

a means of promoting the recognition of good practice

assist accountability, demonstrate efficiency and quality work as well as commitment and dedication

a vital information base for the achievement of consistency in social work intervention.

How and when should case notes be recorded?

Case notes can be recorded manually or electronically and should:

include on each page the name and DOB or other identifying information of the client

be recorded as soon as possible after an interaction or event

be typed or, if handwritten, clearly readable

include the name, signature and profession/role of the author

include the time of contact, particularly where there are a high volume of interactions in a day (AASW, 2016; Sommers-Flanagan, 2009).

What information should be included in a case note?

There are no prescribed rules for what we put in or out of case notes. It depends on the agency rules and our view. However they are legal documents that can be called for by the court. So in writing them consider

Who is going to read them?

How will / can the information be interpreted?

What needs to be there so someone else can go on with the case if you leave?

Put context around any judgements you make, do not just give your opinion (Maple, 2012).

Information recorded about a client should be impartial , accurate and complete with care taken to ensure that:

only details relevant to the provision of a support or service to which the client has consented are recorded

when working with involuntary clients this means recording information relevant to statutory practice

notes are free from derogatory or emotive language

subjective opinions are qualified with relevant background information, theory or research

relevant information is not omitted. (AASW, 2016)

It is important to listen for what is important to the client. Signs that a matter is important are:

Word, phrase or topic repetitions (e.g. “money” may be mentioned four times)

Use of colloquial phrases of emphasis (e.g. ‘after all I said last time’, ‘I mean’, ‘and then where will she be’)

Swearwords (e.g. ‘it’s bloody awful’)

Tone of voice , such as extra loudness or long pauses followed by a strongly expressed phrase (Healy & Mulholland, 2007)

The guiding principle for deciding what information should be included in a case note is whether it is relevant to the service or support being provided. The type of information that is considered relevant may include:

a range of biopsychosocial, environmental and systemic factors impacting on the client; this includes consideration of an individual's culture, religion and spirituality

risk and resilience factors

facts, theory or research underpinning an assessment

a record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence

a record of non-attendance, either by the Social Worker or client, at scheduled and agreed meetings or activities

evidence that the Social Worker and client have discussed their respective legal and ethical responsibilities. This may include:

client rights, responsibilities and complaints processes

the parameters of the service and support being offered and agreed to

issues relating to informed consent, information sharing, confidentiality and privacy

efforts to promote and support client self-determination and autonomy

specific responsibilities to clients in particular settings such as private practice or rural settings as per the relevant Association’s Code of Ethics document

professional boundaries and how dual relationships may be managed

record keeping and freedom of information

discharge planning

relevant legislative requirements and their possible implications for practice

details of reasons and any related actions or outcomes leading up to or following the termination or interruption of a service or support (AASW, 2016). Professional views may often be missing in case notes because social workers position their own subjectivity as irrelevant, or as threatening the achievement of accuracy and comprehensiveness. However, at times it is important to express it, e.g. where it is needed to justify an action (Lillis, 2017).

Other writers provide their own details of what should be included in case notes. In particular Oranga Tamariki (2022a) (the New Zealand Ministry for Children) provides general points when writing case notes. TheraNest (2020) draws together three sources to present a detailed list. This information is included under each of the references in the Supporting Material/References section that concludes this topic.

How should information be presented?

There are a number of case-writing models available to social workers. Some of them provide general guidance for writing case notes while others are specific to a service type or context. In addition, many organisations have policies and procedures around case recording (AASW, 2016). Case note templates are discussed further in the Practice Approach section that follows.

Sommers-Flanagan (2009) suggests the following should be used to structure case notes:

Most reports begin with identifying the reason for referral.

They then examine specific behavioural observations made by the interviewer.

The client’s specific problem is stated in some detail, along with its unique evolution. The history and description of several problems may be included.

For some clients past treatments or history of counselling can be listed.

Relevant medical history should be included, e.g. general health, recent illnesses, chronic physical illnesses or hospitalizations, prescription medications.

Include a social and family history where relevant.

Current ability to manage activities around daily living (ADLs) should be mentioned where relevant. This section can be expanded to include a description of the client’s psychological functioning, cognitive functioning, emotional functioning, or personality functioning.

Include some discussion of diagnostic issues, even if they are broad (e.g. depression, anxiety, substance use, eating disorder). For some clients, more detail may be appropriate.

Include a paragraph around case formulation and treatment plan: how the worker views the case and how the worker is likely to proceed in working with the client.

Can case notes be amended or changed at a later date?

If a change must be made to correct an error or omission, the change can be recorded as a new and separate case note. It is advisable to provide an explanation for its earlier absence or inaccuracy. Add, if possible, a note in the margin of the original case note referring the reader to the additional or amended detail (AASW, 2016).

What are the legislative responsibilities with regard to case notes?

Case notes may be subject to, and can be subpoenaed, for a range of legislative processes and requirements. The nature of these requirements may differ between organisations, districts, States and countries. Therefore it is important for Social Workers to:

be familiar with the specific legal requirements and processes impacting on practice

consider the implications of Federal and State legislation to the recording of case notes

understand how these requirements are implemented within their organisation (where relevant)

understand what policies and procedures may need to be implemented when working in private practice (AASW, 2016).

What should happen with case notes on termination of a service or support?

Termination or interruption of services should be included in case notes. Given termination may be unanticipated (e.g. departure of a social worker), it is particularly important to ensure that case notes are maintained and updated as soon after an interaction or event as practicable (AASW, 2016).

Sharing case notes with the client

It is important that clients can view reports, but they may also misinterpret information in a report unless offered guidance. The following guidelines are suggested:

Inform clients at the outset that records will be kept, and clients can have access to them.

Inform clients that some portions of the records are written in language designed to communicate with other professionals; consequently, the records may not be especially easy to read or understand.

If clients request their records, tell them you would like to review the records with them before releasing them, so as to minimize the possibility that the records are misinterpreted.

When clients request records, schedule an appointment (free of charge) with them to review the records together.

If clients are no longer seeing you, are angry with you, or refuse to meet with you, you can (a) release the records to them without a meeting (and hope the records are not misinterpreted), or (b) agree to release the records only to another licensed professional (who will review them with the client).

Whatever the situation, always discuss the issue of releasing records with your supervisor, rather than acting impulsively on your client's request (Sommers-Flanagan, 2009).

• Practice Approach

One of the themes to emerge from the literature around case notes is how they are “setting dependent” (AASW, 2016); Maple, 2012; TheraNest, 2020). Prescribed rules for what is included or excluded varies from agency to agency. However a number of key points from the Background Material section above. They include the following:

Each page should have the client's name, client's date of birth, social worker’s name and date of the interaction.

Case notes should be written as soon as possible after the interaction.

Consider who is going to read notes and how this should impact on writing style.

Information about a client should be impartial, accurate, complete, and free from emotive language.

Subjective opinions should be qualified with relevant background information, theory or research.

Be clear and consistent – don’t include extra details that are not to the point.

Sign and date the case notes when completed

Relevant information recorded in case notes may include:

The reason for the referral; the client’s specific problems

Evidence that legal and ethical responsibilities of both worker and client have been discussed

Relevant behavioural observations

A range of biopsychosocial, environmental and systemic factors impacting on the client. When relevant:

medical history

social and family history

ability to manage activities of daily living

culture, religion and spirituality

Risk and resilience factors

An assessment supported by facts, theory and/or research

A plan of action based on this assessment

A Selection of Formats for Writing Case Notes

Several different formats exist for writing case notes. TheraNest (2020) highlights three:

S.O.A.P. (Subjective, Objective, Assessment, Plan

D.A.P. (Data, Assessment, Plan)

B.I.R.P. (Behavior, Interventions, Response, Plan)

SOAP (Subjective, Objective, Assessment, Plan)

These four sections try to ensure case notes are complete, yet concise.

Subjective: What the client says about the problem; opinion-based information from the client including their goals, concerns, feelings, perceptions of their own problems. Also include relevant information from other family members or close friends.

Objective: Information that is fact-based, verifiable and quantifiable. This can be direct observations of the client. This might include things like the client’s appearance, body language and other obvious behaviour.

Assessment: Using subjective and objective information to assess the situation; a conclusion or recommendation could be included, with evidence as to why conclusions have been drawn.

Plan: The plan of action, e.g. referrals to other agencies, goals, timeline targets, i.e. the steps to take to assist the client meet their needs (AGS, 2019; Government of Northwest Territories Canada, n.d.; Moore, 2022a).

AGS (2019) provides two examples of case notes to illustrate the above. The AGS website also provides a template social workers can use to record case notes.

Examples of SOAP case notes

DAP (Data, Assessment, Plan)

The Data heading covers everything that occurred during a counselling session, including but not limited to a client’s observable responses, affect, traits, and behavior. This section includes specific, objective information about the session’s focus, what was said, and more, in order to answer the question: “What did I observe?”

Under Assessment, social workers interpret and analyze the data in the previous session. This involves applying some professional subjectivity and may result in clinical hypotheses or findings. Here, social workers might record things like how a session related to a client’s overall treatment goals, a working hypothesis, and/or a probable diagnosis of a client’s condition.

The Plan section is used for making decisions and recommending a plan of treatment for the client. Here, the objective and subjective data from the previous two sections are used to inform a social worker’s strategy or next actions – often between the current session and the next. This could include recommendations for therapy or lifestyle changes, among other short- and long-term treatments (Moore, 2022b).

The key difference between SOAP and DAP formats is that the former breaks down the information about a session into two discrete sections, which can be highly useful in healthcare contexts where medications, blood results, and other clinical data can inform a patient’s treatment (Moore, 2022b).

BIRP (Behaviour, Interventions, Response, Plan)

Behavior (Presenting the Problem) This section records the subjective and objective details that were observed (CF SOAP outline above). This section can also contain details about the session itself, such as where it took place.

Example: Met with client X in the office. The most recent assessment shows they are presenting symptoms of anxiety. Today they showed signs of exhaustion, lack of focus, and looked tired. They reported not being able to sleep in the past week and feeling overwhelmed by work.

Interventions This section outlines the methods used to reach the goals and objectives of the therapy. It’s a concise summary of the conversation, focusing strongly on the therapist’s actions and the patient’s reactions.

Example: Through client-centered techniques, this writer encouraged the patient to expand their thoughts about their work. Negative thoughts were identified and challenged. The patient was asked to see if there is a link between their insomnia and the stressful period at work. The connection was successfully made and normalized through discussion. The conversation then focused on the specific work-related triggers that may have led to insomnia. A mild sleep aid was prescribed.

Response In this section, the therapist should record the client’s response to the intervention, including what the client said and how they reacted.

Example: The patient initially rejected the link between their insomnia and stress at work. When asked how work made them feel, the patient became silent, reduced eye contact, and disengaged from the conversation with the writer. After a few moments of thinking, the patient was able to describe their own feelings in relation to their work.

Plan The plan outlines when the next session will take place, and its focus.

Example: The next appointment scheduled for September 16, will assess the client’s response to the sleep aid and reassess their feelings about work.

https://quenza.com/blog/girp-notes/

The GIRP framework offers a powerful communication tool by delivering a streamlined, concise, and organized account of a patient or client’s journey. GIRP notes highlight key developments and treatment plans , becoming an invaluable asset for all stakeholders.

What is a GIRP note?

The acronym GIRP stands for: G oal, I ntervention, R esponse, and P lan.

Goal GIRP notes always start with a goal. The goal describes what the patient wants to get out of therapy or coaching. You might include both short and long-term goals in this first section. For example: Janine has been attending fortnightly psychotherapy sessions to get better control of her social anxiety and agoraphobia. Long-term, she would like to have a more active social life. However, at present, her main goal is to start doing her grocery shopping in person again. Janine feels this is a safe and achievable goal for her to build some positive momentum.

Intervention The intervention simply describes the techniques, methods, or strategies the practitioner and client are using to work toward the desired change.

So, in Janine’s case, the intervention section might read: Therapist and client discussed gradual exposure techniques to start working up to completing a full in-person grocery shop. Or, for another person: Discussed client’s limiting beliefs around her capacity to successfully launch an online business. Introduced the concept of focusing on strengths rather than weaknesses. Then, prompted the client to come up with some empowering affirmations she can use when self-doubt is becoming an issue.

Response The response section provides an objective account of the individual’s reaction or progress in response to the intervention. This forces the practitioner to hone in on whether what they are doing in session is working and adjust course if necessary. In coaching, an example would be: Client struggled immensely with identifying strengths. By the end of the session we identified 3: creativity, persistence, and ability to learn new things. Did not get to move onto affirmations before the end of the session.

Plan The plan sets out the forthcoming steps, giving a clear roadmap for future treatment, services, and/or client tasks, based on insights gained from the individual’s response to past interventions.

For example: Janine to undertake 2 more trips for grocery shopping before next session. If successful, therapist and patient to decide on a new goal. May be suitable to include more social interaction, in line with long-term goal of having an active social life.

Benefits of GIRP Notes

The two most significant benefits of GIRP notes are that they:

1. Enhance communication between the client and professionals involved in a case resulting in a collaborative approach to care and a strong therapeutic relationship.

2. Maintain a focus on the individual’s goals.

Biopsychosocial-Spiritual Approach (BPSS)

The BPSS is used quite frequently by social workers, especially in their initial dealings with clients. The following is a template that could be adapted as necessary for different clients. Other templates for the BPSS can be found in a separate topic on this website at https://www.thesocialworkgraduate.com/post/bio-psychosocial-spiritual-assessment

_________________________________________________________________________________

Client Name:

Client D.O.B:

Client address:

Client contact details:

Referred by:

Presenting problem:

Family Structure/genogram:

Medical / psychological history:

Current medications:

Employment / education:

Other issues: Should check areas in BPSS to see if any other topics should be included

Planned intervention and referrals:

_____________________________________________________________________________

Pacheco (2014) suggests social workers can develop a template that can be written over when taking notes.The template can contain prompts to ensure the social worker does not forget to touch on certain areas. An example using the BPSS approach is shown on the right.

This is quite simple to make: type up your page with the prompts, highlight the prompts, and choose a light colour from the available font colours, e.g.tan background 2.

Pacheco’s approach could be used with other approaches too, such as SOAP, DAP and BIRP.

A number of other writers suggest case notes templates, and these have been included under their reference in the following Supporting Material / References section.

Healy and Mulholland (2007) suggest three approaches: topic sentences, problems to be solved, and expressing client concerns.

Oranga Tamariki (2022b) provide an example of a good and poor case note

Social Work Haven (2021) has developed a case notes cheat sheet

Sommers-Flanagan (2009) provide a detailed intake report template.

Supporting Material/References

AASW: Australian Association of Social Workers. (2016). Case notes . Retrieved from https://www.aasw.asn.au/document/item/2356

AGS: Airiodion Global Services. (2019). A simple (but detailed) guide on different types & stages of social work processes . Retrieved frpm https://www.airiodion.com/social-work-process/

Healy, K., & Mulholland, J. (2007). Writing Case Records. In K Healy & J Mulholland (Eds.), Writing Skills for Social Workers (pp. 68-86) . Sage Publications.

Three Methods for Writing Case Notes

Topic sentences—provide the gist but leave out the detail

Problems to be solved

Expressing client concerns—state the client’s concerns as well as the social worker’s professional judgement

An example of each of the above follows based on this situation: The grandmother said: It was last Friday she came round, late as usual, and she hadn’t brought me any money to buy food for the kid after all I said last time it happened - no money and no food either - I mean I don’t mind looking after the kid - it’s bloody awful the way she treats that child - but on my pension I can’t pay for its food and that - I mean if she doesn’t give me some money soon I will have to stop caring for the kid and then where will she be?’

Topic sentences :

This case is about childcare by grandmother. Grandmother is client. The mother is in paid employment; she finds it difficult to supply money to the carer, and to pick up the child on time. The carer is unhappy about the money situation, and to lesser degree the time problem, and threatens to stop the caring.

Problems to be solved :

This case is about childcare by grandmother. Problem 1 - money, since mother is erratic about providing it.

Problem 2 - time of child collection, since mother is often late.

Problem 3 - carer is unhappy about the money situation, and to a lesser degree the time problem, and threatens to stop the caring.

[You may wish to go one step further and alert the attention of a specific team member by writing Problem 3 as : Problem 3 - ’In my view, the carer may need counselling’ , or ’Carer and mother may need mediation’.]

Expressing client concerns :

Client, grandmother as carer, complained about child’s mother supplying no money and being late. She warned that she could not continue with the childcare unless she was paid.

Lillis, T. (2017). Imagined, prescribed and actual text trajectories: The ‘problem’ with case notes in contemporary social work. Text and Talk, 37 (4), 485–508. http://dx.doi.org/doi:10.1515/text-2017-0013

Government of Northwest Territories Canada. (n.d.). SOAP case notes guide . Retrieved from https://www.hss.gov.nt.ca/professionals/sites/professionals/files/resources/soap-case-notes-guide.pdf

GoodTherapy. (2020). For social workers: Tips for writing case notes . Retrieved from https://www.goodtherapy.org/for-professionals/business-management/private-practices/article/for-social-workers-tips-for-writing-case-notes

Maple, M. (2012). Case notes . Lecture notes, HSSW 100, University of New England, Australia.

Miller, K. (2022). BIRP notes: A complete guide on the BIRP note-taking forma t. Retrieved from https://quenza.com/blog/birp-notes/

Moore, C. (2022a). Writing SOAP notes, step-by-step: Examples + templates . Retrieved from https://quenza.com/blog/soap-note/

Moore, C. (2022b). How to write DAP notes: 5 best templates and examples . Retrieved from https://quenza.com/blog/dap-notes/

Oranga Tamariki (New Zealand Ministry for Children). (2022a). Keeping accurate records – guidance . Retrieved from https://practice.orangatamariki.govt.nz/practice-approach/practice-standards/keep-accurate-records/keep-accurate-records-guidance/

Oranga Tamariki - New Zealand Ministry for Children (2022a) suggests the following general points in providing guidance for social workers when writing case records. Each point below is expanded in the actual document.

Implement the practice standards for each tamaiti (child) in case notes, assessments, plans and reports

Record the process of engaging with, assessing, making decisions and reasons for decisions

Ensure what is recorded is easily understood

Provide adequate support if tamariki (children) want access to records

Keep personal information safe and secure

Document any key decisions made, or actions taken, the rationale for decisions or actions and the next steps.

Records identify the key people with whom engagement has occurred

Document views on relevant people involved in the case and how this has informed decision-making

Develop a chronology of critical key events and changes for te tamaiti (the child) and whanau (family) across their lifespan

Document how tamaiti (child), their whanau (extended family), caregivers or others working with the have responded to social worker decisions

Choose an appropriate communicate approach when communicating with clients

Include in notes how the family responds to decisions made

Document any oversight/approval obtained for key decisions that require it

Record discussions, key points and decisions made during supervision or case consults, including next steps

Review records often to keep the current and accurate

Oranga Tamariki (New Zealand Ministry for Children). (2022b). Case note examples . Retrieved from https://practice.orangatamariki.govt.nz/previous-practice-centre/policy/recording/key-information/case note-examples/

Pacheco, I. (2014). Note taking templates for clinical social work . Retrieved from http://socialworktech.com/2014/06/23/note-taking-templates-for-clinical-social-work/

Social Work Haven. (2021). Sample case notes from social work you can learn from . Retrieved from https://socialworkhaven.com/sample-case-notes-for-social-work/

Case notes cheat sheet

Date and time

Reason for contact or conversation

Capacity to make decisions around subject being discussed if applicable

Views of the person

Views of others

What did you see?

What did you do?

Any risks identified

Did you consult or share information with anyone? If so, why?

Your professional opinion and analysis

Action plan

Somers-Flanagan, J., & Sommers-Flanagan, R. (2009). Intake interviewing and report writing. In J. Sommers-Flanagan & R. Sommers-Flanagan (Eds.). Clinical interviewing (4th ed., 175-212). John Wiley & Sons.

Sample Intake Report Outline

Use the following intake report outline as a guide for writing a thorough intake report. Keep in mind that this outline is lengthy and therefore, in practical clinical situations, you will need to select what to include and what to omit in your client reports.

--------------------------------------------------------------

NAME: DATE OF BIRTH: AGE: DATE OF INTAKE: INTAKE INTERVIEWER: DATE OF REPORT:

I. Identifying Information and Reason for Referral

A. Client name

D. Racial/Ethnic information

E. Marital status

F. Referral source (and telephone number, when possible)

G. Reason for referral '(why has the client been sent to you for a consultation/intake session?)

H. Presenting complaint (use a quote from me client to describe the complaint)

II. Behavioral Observations (and Mental Status Examination)

A. Appearance upon presentation (including comments about contact, body posture, and facial expression)

B. Quality and quantity of speech and responsivity to questioning

C. Client description of mood (use a quote in the report when appropriate)

D. Primary thought content (including presence or absence of suicidal ideation)

E. Level of cooperation with the interview

F. Estimate of adequacy of the data obtained

III. History of the Present Problem (or iIlness)

A. Include one paragraph describing the client's presenting problems and associated current stressors

B. Include one or two paragraphs outlining when the problem initially began and the course or development of symptoms

C. Repeat, as needed, paragraph-long descriptions of additional current problems identified during the intake interview (client problems are usually organized using diagnostic-DSM-groupings, however, suicide ideation, homicide ideation, relationship problems, etc., may be listed)

D. Follow, as appropriate, with relevant negative or rule-out statements (e.g., with a clinically depressed client, it is important to rule out mania: "The client denied any history ofmanic episodes.")

IV. Past Treatment (Psychiatric) History and Family Treatment (Psychiatric) History

A. Include a description of previous clinical problems or episodes not included in the previous section (e.g., if the client is presenting with a problem of clinical anxiety, but also has a history of treatment for an eating disorder, the eating disorder should be noted here)

B. Description of previous treatment received, including hospitalization, medications, psychotherapy or counselling, case management, and so on.

C. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins)

D. Also include a list of any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease)

V. Relevant Medical History

A. List and briefly describe past hospitalizations and major medical illnesses (e.g., asthma, mv positive, hypertension)

B. Include a description of the client's current health status (it's good to use a client quote or physician quote here)

C. Current medications and dosages

D. Primary care physician (and/or specialty physician) and telephone numbers

VI. Developmental History (This section is optional and is most appropriate for inclusion in child/adolescent cases.)

VII. Social and Family History

A. Early memories/experiences (including, when appropriate, descriptions of parents and possible abuse or childhood trauma)

B. Educational history

C. Employment history

D. Military history

E. Romantic relationship history

F. Sexual history

G. Aggression/Violence history

H. Alcohol/Drug history (if not previously covered as a primary problem area)

I. Legal history

J. Recreational history

K. Spiritual/Religious history

VIII. Current situation and Functioning

A. A description of typical daily activities

B. Self-perceived strengths and weaknesses

C. Ability to complete normal activities of daily living

IX. Diagnostic Impressions (This section should include a discussion of diagnostic issues or a listing of assigned diagnoses.)

A. Brief discussion of diagnostic issues

B. Multiaxial diagnosis from DSM

X. Case Formulation and Treatment Plan

A. Include a paragraph description of how you conceptualize the case. This description will provide a foundation for how you will work with this per- son. For example, a behaviorist will emphasize reinforcement contingencies that have influenced the client's development of symptoms and that will likely aid in alleviation of client symptoms. Alternatively, a psycho- analytically oriented interviewer will emphasize personality dynamics and historically significant and repeating relationship conflicts.

B. Include a paragraph description (or list) of recommended treatment approaches.

TheraNest. (2020). Elements of effective case notes for social wor k. Retrieved from https://theranest.com/blog/elements-of-effective-case-notes-for-social-work/

The guiding principle for writing effective case notes is to include content relevant to the service(s) or support provided. The specific content will vary based on your specific situation, but AASW broadly recommends the following:

The biopsychosocial, environmental and systemic factors impacting the client, including the client’s culture, religion/spirituality

Facts, theory or research underpinning an assessment

A record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence

A record of non-attendance (by either you or your client) at scheduled and agreed meetings or activities

Evidence that you and your client have discussed your respective legal and ethical responsibilities — such as client rights and responsibilities, informed consent, confidentiality and privacy, professional boundaries, freedom of information, etc.

In addition to these broad guidelines, experts also recommend including the following specific pieces of information in each case note:

Topics discussed during the session

How the session related to the treatment plan

How the treatment plan goals and objectives are being met

Interventions and techniques used during the session and their effectiveness

Clinical observations

Progress or setbacks

Signs, symptoms and any increase or decrease in the severity of behaviors as they relate to any diagnosis used

Homework assigned, results and compliance

The client’s current strengths and challenges

Additionally, the following have to be included in case notes:

Demographic information

Prognosis and treatment plan

Progress to date

Dates of service

Who attended the sessions

Financial issues (billing, costs, payments, etc.)

This may seem like a lot of information to present, but case notes with this data will help document not only what took place in the session, but also your decision-making process and how you implemented treatment and intervention

Recent Posts

An Everyday Social Work Approach

Bio-Psychosocial-Spiritual Assessment

A sample case study: Mrs Brown

On this page, social work report, social work report: background, social work report: social history, social work report: current function, social work report: the current risks, social work report: attempts to trial least restrictive options, social work report: recommendation, medical report, medical report: background information, medical report: financial and legal affairs, medical report: general living circumstances.

This is a fictitious case that has been designed for educative purposes.

Mrs Beryl Brown URN102030 20 Hume Road, Melbourne, 3000 DOB: 01/11/33

Date of application: 20 August 2019

Mrs Beryl Brown (01/11/33) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight. On admission, Mrs Brown was diagnosed with a right sided stroke, which has left her with moderate weakness in her left arm and leg. A diagnosis of vascular dementia was also made, which is overlaid on a pre-existing diagnosis of Alzheimer’s disease (2016). Please refer to the attached medical report for further details.

I understand that Mrs Brown has been residing in her own home, a two-story terrace house in Melbourne, for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job. The eldest daughter Catherine lives on the Gold Coast with her family. Mrs Brown is a retired school teacher and she and both daughters describe her as a very private woman who has never enjoyed having visitors in her home. Mrs Brown took much encouragement to accept cleaning and shopping assistance once a week after her most recent admission; however, she does not agree to increase service provision. Jean has Enduring Power of Attorney (EPOA) paperwork that indicates that Mrs Brown appointed her under an EPOA two years ago. She does not appear to have appointed a medical treatment decision maker or any other decision-supporter.

I also understand from conversations with her daughters that Jean and Mrs Brown have always been very close and that there is a history of long-standing conflict between Catherine and Jean. This was exacerbated by the death of their father. Both daughters state they understand the impact of the stroke on their mother’s physical and cognitive functioning, but they do not agree on a discharge destination. Mrs Brown lacks insight into her care needs and says she will be fine once she gets back into her own home. Repeated attempts to discuss options with all parties in the same room have not resulted in a decision that is agreeable to all parties.

Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars. She is currently requiring one to two people to assist her into and out of bed and one person with managing tasks associated with post-toilet hygiene. She can walk slowly for short distances with a four-wheel frame with one person to supervise. She benefits from prompting to use her frame; she needs someone to cut her food and to set her up to eat and drink regularly and to manage her medication routine. She requires one person to assist her to manage her insulin twice daily.

The team believe that Mrs Brown’s capacity for functional improvement has plateaued in the last ten days. They recommend that it is in her best interests to be discharged to a residential care setting due to her need for one to two people to provide assistance with the core tasks associated with daily living. Mrs Brown is adamant that she wants to return home to live with Jean who she states can look after her. Jean, who has a history of chronic back pain, has required several admissions to hospital over the past five years, and states she wants to be able to care for her mother at home. Jean states she is reluctant to agree to extra services as her mother would not want this. Her sister Catherine is concerned that Jean has not been coping and states that given this is the third admission to hospital in a period of few months, believes it is now time for her mother to enter residential care. Catherine states that she is very opposed to her mother being discharged home.

Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke. She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits. Mrs Brown is also at risk of further significant functional decline which may exacerbate Jean’s back pain. Jean has stated she is very worried about where she will live if her mother is to enter residential care.

We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home. During this training Jean reported significant pain when transferring her mother from the bed and stated she would prefer to leave her mother in bed until she was well enough to get out with less support.

The team provided education to both Jean and Catherine about the progressive impact of their mother’s multiple conditions on her functioning. The occupational therapist completed a home visit and recommended that the downstairs shower be modified so that a commode can be placed in it safely and the existing dining room be converted into a bedroom for Mrs Brown. Mrs Brown stated she would not pay for these modifications and Jean stated she did not wish to go against her mother’s wishes. The team encouraged Mrs Brown to consider developing a back-up plan and explore residential care options close to her home so that Jean could visit often if the discharge home failed. Mrs Brown and Jean refused to consent to proceed with an Aged Care Assessment that would enable Catherine to waitlist her mother’s name at suitable aged care facilities. We proceeded with organising a trial overnight visit. Unfortunately, this visit was not successful as Jean and Catherine, who remained in Melbourne to provide assistance, found it very difficult to provide care without the use of an accessible bathroom. Mrs Brown remains adamant that she will remain at home. The team is continuing to work with the family to maximise Mrs Brown’s independence, but they believe that it is unlikely this will improve. I have spent time with Jean to explore her adjustment to the situation, and provided her with information on community support services and residential care services. I have provided her with information on the Transition Care Program which can assist families to work through all the logistics. I have provided her with more information on where she could access further counselling to explore her concerns. I have sought advice on the process and legislative requirements from the Office of the Public Advocate’s Advice Service. I discussed this process with the treating team and we decided that it was time to lodge an application for guardianship to VCAT.

The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort. We believe that this is the most suitable arrangement as her daughters are not in agreement about what is in their mother’s best interests. We also believe that there is a potential conflict of interest as Jean has expressed significant concern that her mother’s relocation to residential care will have an impact on her own living arrangements.

Mrs Brown’s medical history includes Alzheimer’s disease; type II diabetes; hypertension; high cholesterol and osteoarthritis. She was admitted to Hume Hospital on 3 March 2019 following a stroke that resulted in moderate left arm and leg weakness. This admission was the third hospital admission in the past year. Other admissions have been for a urinary tract infection, and a fall in the context hypoglycaemia (low blood sugars), both of which were complicated by episodes of delirium.

She was transferred to the subacute site under my care, a week post her admission, for slow-stream rehabilitation, cognitive assessment and discharge planning.

Mrs Brown was diagnosed with Alzheimer’s disease by Dr Joanne Winters, Geriatrician, in April 2016. At that time, Mrs Brown scored 21/30 on the Standardised Mini-Mental State Examination (SMMSE). During this admission, Mrs Brown scored 15/30. I have undertaken cognitive assessment and agree with the diagnosis; further cognitive decline has occurred in the context of the recent stroke. There are global cognitive deficits, but primarily affecting memory, attention and executive function (planning, problem solving, mental flexibility and abstract reasoning). The most recent CT-Brain scan shows generalised atrophy along with evidence of the new stroke affecting the right frontal lobe. My assessments suggest moderate to severe mixed Alzheimer’s and vascular dementia.

While able to recall some key aspects of her financial affairs, including the general monetary value of her pension and regular expenses, Mrs Brown was unable to account for recent expenditure (for repairs to her home) or provide an estimate of its value, and had difficulty describing her investments. In addition, I consider that she would be unable to make complex financial decisions due to her level of cognitive impairment. Accordingly, I am of the view that Mrs Brown now lacks capacity to make financial decisions.

Mrs Brown states that she previously made an Enduring Power of Attorney (EPOA) but could no longer recall aspects of the EPOA, such as when it would commence and the nature of the attorney’s powers. Moreover, she confused the EPOA with her will. Her understanding of these matters did not improve with education, and therefore I consider that she no longer has capacity to execute or revoke an EPOA.

Mrs Brown acknowledges that she needs some assistance but lacks insight into the type of assistance that she requires, apart from home help for cleaning and shopping. She does not appreciate her risk of falling. She is unable to get in and out of bed without at least one person assisting her. She frequently forgets to use her gait aid when mobilising and is not able to describe how she would seek help in the event of falling. She is not able to identify or describe how she would manage her blood sugar levels, and this has not improved with education. Accordingly, I consider that she lacks capacity to make decisions about accommodation arrangements and services.

Mrs Brown does not agree with the treating team’s recommendation to move into residential care and maintains her preference to return home. This is in spite of a failed overnight trial at home with both her daughters assisting her. Unfortunately, she was unable to get out of bed to get to the toilet and required two people to assist her to do so in the morning. In light of these matters, and in the context of family disagreement regarding the matter, the team recommends that the Office of the Public Advocate be appointed as a guardian of last resort.

Reviewed 22 July 2022

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6 SFBT in Action: Case Examples of School Social Workers Using SFBT

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• Published: April 2008
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This chapter presents five case studies which show how school social workers adapted solution-focused brief therapy (SFBT) to their school contexts. Using a variety of treatment modalities (family, small group, and macropractice), these school social workers demonstrate how flexible and powerful SFBT ideas can be in a school setting.

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Human Subjects Office

Medical terms in lay language.

Please use these descriptions in place of medical jargon in consent documents, recruitment materials and other study documents. Note: These terms are not the only acceptable plain language alternatives for these vocabulary words.

This glossary of terms is derived from a list copyrighted by the University of Kentucky, Office of Research Integrity (1990).

For clinical research-specific definitions, see also the Clinical Research Glossary developed by the Multi-Regional Clinical Trials (MRCT) Center of Brigham and Women’s Hospital and Harvard  and the Clinical Data Interchange Standards Consortium (CDISC) .

Alternative Lay Language for Medical Terms for use in Informed Consent Documents

A   B   C   D   E   F   G   H   I  J  K   L   M   N   O   P   Q   R   S   T   U   V   W  X  Y  Z

ABDOMEN/ABDOMINAL body cavity below diaphragm that contains stomach, intestines, liver and other organs ABSORB take up fluids, take in ACIDOSIS condition when blood contains more acid than normal ACUITY clearness, keenness, esp. of vision and airways ACUTE new, recent, sudden, urgent ADENOPATHY swollen lymph nodes (glands) ADJUVANT helpful, assisting, aiding, supportive ADJUVANT TREATMENT added treatment (usually to a standard treatment) ANTIBIOTIC drug that kills bacteria and other germs ANTIMICROBIAL drug that kills bacteria and other germs ANTIRETROVIRAL drug that works against the growth of certain viruses ADVERSE EFFECT side effect, bad reaction, unwanted response ALLERGIC REACTION rash, hives, swelling, trouble breathing AMBULATE/AMBULATION/AMBULATORY walk, able to walk ANAPHYLAXIS serious, potentially life-threatening allergic reaction ANEMIA decreased red blood cells; low red cell blood count ANESTHETIC a drug or agent used to decrease the feeling of pain, or eliminate the feeling of pain by putting you to sleep ANGINA pain resulting from not enough blood flowing to the heart ANGINA PECTORIS pain resulting from not enough blood flowing to the heart ANOREXIA disorder in which person will not eat; lack of appetite ANTECUBITAL related to the inner side of the forearm ANTIBODY protein made in the body in response to foreign substance ANTICONVULSANT drug used to prevent seizures ANTILIPEMIC a drug that lowers fat levels in the blood ANTITUSSIVE a drug used to relieve coughing ARRHYTHMIA abnormal heartbeat; any change from the normal heartbeat ASPIRATION fluid entering the lungs, such as after vomiting ASSAY lab test ASSESS to learn about, measure, evaluate, look at ASTHMA lung disease associated with tightening of air passages, making breathing difficult ASYMPTOMATIC without symptoms AXILLA armpit

BENIGN not malignant, without serious consequences BID twice a day BINDING/BOUND carried by, to make stick together, transported BIOAVAILABILITY the extent to which a drug or other substance becomes available to the body BLOOD PROFILE series of blood tests BOLUS a large amount given all at once BONE MASS the amount of calcium and other minerals in a given amount of bone BRADYARRHYTHMIAS slow, irregular heartbeats BRADYCARDIA slow heartbeat BRONCHOSPASM breathing distress caused by narrowing of the airways

CARCINOGENIC cancer-causing CARCINOMA type of cancer CARDIAC related to the heart CARDIOVERSION return to normal heartbeat by electric shock CATHETER a tube for withdrawing or giving fluids CATHETER a tube placed near the spinal cord and used for anesthesia (indwelling epidural) during surgery CENTRAL NERVOUS SYSTEM (CNS) brain and spinal cord CEREBRAL TRAUMA damage to the brain CESSATION stopping CHD coronary heart disease CHEMOTHERAPY treatment of disease, usually cancer, by chemical agents CHRONIC continuing for a long time, ongoing CLINICAL pertaining to medical care CLINICAL TRIAL an experiment involving human subjects COMA unconscious state COMPLETE RESPONSE total disappearance of disease CONGENITAL present before birth CONJUNCTIVITIS redness and irritation of the thin membrane that covers the eye CONSOLIDATION PHASE treatment phase intended to make a remission permanent (follows induction phase) CONTROLLED TRIAL research study in which the experimental treatment or procedure is compared to a standard (control) treatment or procedure COOPERATIVE GROUP association of multiple institutions to perform clinical trials CORONARY related to the blood vessels that supply the heart, or to the heart itself CT SCAN (CAT) computerized series of x-rays (computerized tomography) CULTURE test for infection, or for organisms that could cause infection CUMULATIVE added together from the beginning CUTANEOUS relating to the skin CVA stroke (cerebrovascular accident)

DERMATOLOGIC pertaining to the skin DIASTOLIC lower number in a blood pressure reading DISTAL toward the end, away from the center of the body DIURETIC "water pill" or drug that causes increase in urination DOPPLER device using sound waves to diagnose or test DOUBLE BLIND study in which neither investigators nor subjects know what drug or treatment the subject is receiving DYSFUNCTION state of improper function DYSPLASIA abnormal cells

ECHOCARDIOGRAM sound wave test of the heart EDEMA excess fluid collecting in tissue EEG electric brain wave tracing (electroencephalogram) EFFICACY effectiveness ELECTROCARDIOGRAM electrical tracing of the heartbeat (ECG or EKG) ELECTROLYTE IMBALANCE an imbalance of minerals in the blood EMESIS vomiting EMPIRIC based on experience ENDOSCOPIC EXAMINATION viewing an  internal part of the body with a lighted tube  ENTERAL by way of the intestines EPIDURAL outside the spinal cord ERADICATE get rid of (such as disease) Page 2 of 7 EVALUATED, ASSESSED examined for a medical condition EXPEDITED REVIEW rapid review of a protocol by the IRB Chair without full committee approval, permitted with certain low-risk research studies EXTERNAL outside the body EXTRAVASATE to leak outside of a planned area, such as out of a blood vessel

FDA U.S. Food and Drug Administration, the branch of federal government that approves new drugs FIBROUS having many fibers, such as scar tissue FIBRILLATION irregular beat of the heart or other muscle

GENERAL ANESTHESIA pain prevention by giving drugs to cause loss of consciousness, as during surgery GESTATIONAL pertaining to pregnancy

HEMATOCRIT amount of red blood cells in the blood HEMATOMA a bruise, a black and blue mark HEMODYNAMIC MEASURING blood flow HEMOLYSIS breakdown in red blood cells HEPARIN LOCK needle placed in the arm with blood thinner to keep the blood from clotting HEPATOMA cancer or tumor of the liver HERITABLE DISEASE can be transmitted to one’s offspring, resulting in damage to future children HISTOPATHOLOGIC pertaining to the disease status of body tissues or cells HOLTER MONITOR a portable machine for recording heart beats HYPERCALCEMIA high blood calcium level HYPERKALEMIA high blood potassium level HYPERNATREMIA high blood sodium level HYPERTENSION high blood pressure HYPOCALCEMIA low blood calcium level HYPOKALEMIA low blood potassium level HYPONATREMIA low blood sodium level HYPOTENSION low blood pressure HYPOXEMIA a decrease of oxygen in the blood HYPOXIA a decrease of oxygen reaching body tissues HYSTERECTOMY surgical removal of the uterus, ovaries (female sex glands), or both uterus and ovaries

IATROGENIC caused by a physician or by treatment IDE investigational device exemption, the license to test an unapproved new medical device IDIOPATHIC of unknown cause IMMUNITY defense against, protection from IMMUNOGLOBIN a protein that makes antibodies IMMUNOSUPPRESSIVE drug which works against the body's immune (protective) response, often used in transplantation and diseases caused by immune system malfunction IMMUNOTHERAPY giving of drugs to help the body's immune (protective) system; usually used to destroy cancer cells IMPAIRED FUNCTION abnormal function IMPLANTED placed in the body IND investigational new drug, the license to test an unapproved new drug INDUCTION PHASE beginning phase or stage of a treatment INDURATION hardening INDWELLING remaining in a given location, such as a catheter INFARCT death of tissue due to lack of blood supply INFECTIOUS DISEASE transmitted from one person to the next INFLAMMATION swelling that is generally painful, red, and warm INFUSION slow injection of a substance into the body, usually into the blood by means of a catheter INGESTION eating; taking by mouth INTERFERON drug which acts against viruses; antiviral agent INTERMITTENT occurring (regularly or irregularly) between two time points; repeatedly stopping, then starting again INTERNAL within the body INTERIOR inside of the body INTRAMUSCULAR into the muscle; within the muscle INTRAPERITONEAL into the abdominal cavity INTRATHECAL into the spinal fluid INTRAVENOUS (IV) through the vein INTRAVESICAL in the bladder INTUBATE the placement of a tube into the airway INVASIVE PROCEDURE puncturing, opening, or cutting the skin INVESTIGATIONAL NEW DRUG (IND) a new drug that has not been approved by the FDA INVESTIGATIONAL METHOD a treatment method which has not been proven to be beneficial or has not been accepted as standard care ISCHEMIA decreased oxygen in a tissue (usually because of decreased blood flow)

LAPAROTOMY surgical procedure in which an incision is made in the abdominal wall to enable a doctor to look at the organs inside LESION wound or injury; a diseased patch of skin LETHARGY sleepiness, tiredness LEUKOPENIA low white blood cell count LIPID fat LIPID CONTENT fat content in the blood LIPID PROFILE (PANEL) fat and cholesterol levels in the blood LOCAL ANESTHESIA creation of insensitivity to pain in a small, local area of the body, usually by injection of numbing drugs LOCALIZED restricted to one area, limited to one area LUMEN the cavity of an organ or tube (e.g., blood vessel) LYMPHANGIOGRAPHY an x-ray of the lymph nodes or tissues after injecting dye into lymph vessels (e.g., in feet) LYMPHOCYTE a type of white blood cell important in immunity (protection) against infection LYMPHOMA a cancer of the lymph nodes (or tissues)

MALAISE a vague feeling of bodily discomfort, feeling badly MALFUNCTION condition in which something is not functioning properly MALIGNANCY cancer or other progressively enlarging and spreading tumor, usually fatal if not successfully treated MEDULLABLASTOMA a type of brain tumor MEGALOBLASTOSIS change in red blood cells METABOLIZE process of breaking down substances in the cells to obtain energy METASTASIS spread of cancer cells from one part of the body to another METRONIDAZOLE drug used to treat infections caused by parasites (invading organisms that take up living in the body) or other causes of anaerobic infection (not requiring oxygen to survive) MI myocardial infarction, heart attack MINIMAL slight MINIMIZE reduce as much as possible Page 4 of 7 MONITOR check on; keep track of; watch carefully MOBILITY ease of movement MORBIDITY undesired result or complication MORTALITY death MOTILITY the ability to move MRI magnetic resonance imaging, diagnostic pictures of the inside of the body, created using magnetic rather than x-ray energy MUCOSA, MUCOUS MEMBRANE moist lining of digestive, respiratory, reproductive, and urinary tracts MYALGIA muscle aches MYOCARDIAL pertaining to the heart muscle MYOCARDIAL INFARCTION heart attack

NASOGASTRIC TUBE placed in the nose, reaching to the stomach NCI the National Cancer Institute NECROSIS death of tissue NEOPLASIA/NEOPLASM tumor, may be benign or malignant NEUROBLASTOMA a cancer of nerve tissue NEUROLOGICAL pertaining to the nervous system NEUTROPENIA decrease in the main part of the white blood cells NIH the National Institutes of Health NONINVASIVE not breaking, cutting, or entering the skin NOSOCOMIAL acquired in the hospital

OCCLUSION closing; blockage; obstruction ONCOLOGY the study of tumors or cancer OPHTHALMIC pertaining to the eye OPTIMAL best, most favorable or desirable ORAL ADMINISTRATION by mouth ORTHOPEDIC pertaining to the bones OSTEOPETROSIS rare bone disorder characterized by dense bone OSTEOPOROSIS softening of the bones OVARIES female sex glands

PARENTERAL given by injection PATENCY condition of being open PATHOGENESIS development of a disease or unhealthy condition PERCUTANEOUS through the skin PERIPHERAL not central PER OS (PO) by mouth PHARMACOKINETICS the study of the way the body absorbs, distributes, and gets rid of a drug PHASE I first phase of study of a new drug in humans to determine action, safety, and proper dosing PHASE II second phase of study of a new drug in humans, intended to gather information about safety and effectiveness of the drug for certain uses PHASE III large-scale studies to confirm and expand information on safety and effectiveness of new drug for certain uses, and to study common side effects PHASE IV studies done after the drug is approved by the FDA, especially to compare it to standard care or to try it for new uses PHLEBITIS irritation or inflammation of the vein PLACEBO an inactive substance; a pill/liquid that contains no medicine PLACEBO EFFECT improvement seen with giving subjects a placebo, though it contains no active drug/treatment PLATELETS small particles in the blood that help with clotting POTENTIAL possible POTENTIATE increase or multiply the effect of a drug or toxin (poison) by giving another drug or toxin at the same time (sometimes an unintentional result) POTENTIATOR an agent that helps another agent work better PRENATAL before birth PROPHYLAXIS a drug given to prevent disease or infection PER OS (PO) by mouth PRN as needed PROGNOSIS outlook, probable outcomes PRONE lying on the stomach PROSPECTIVE STUDY following patients forward in time PROSTHESIS artificial part, most often limbs, such as arms or legs PROTOCOL plan of study PROXIMAL closer to the center of the body, away from the end PULMONARY pertaining to the lungs

QD every day; daily QID four times a day

RADIATION THERAPY x-ray or cobalt treatment RANDOM by chance (like the flip of a coin) RANDOMIZATION chance selection RBC red blood cell RECOMBINANT formation of new combinations of genes RECONSTITUTION putting back together the original parts or elements RECUR happen again REFRACTORY not responding to treatment REGENERATION re-growth of a structure or of lost tissue REGIMEN pattern of giving treatment RELAPSE the return of a disease REMISSION disappearance of evidence of cancer or other disease RENAL pertaining to the kidneys REPLICABLE possible to duplicate RESECT remove or cut out surgically RETROSPECTIVE STUDY looking back over past experience

SARCOMA a type of cancer SEDATIVE a drug to calm or make less anxious SEMINOMA a type of testicular cancer (found in the male sex glands) SEQUENTIALLY in a row, in order SOMNOLENCE sleepiness SPIROMETER an instrument to measure the amount of air taken into and exhaled from the lungs STAGING an evaluation of the extent of the disease STANDARD OF CARE a treatment plan that the majority of the medical community would accept as appropriate STENOSIS narrowing of a duct, tube, or one of the blood vessels in the heart STOMATITIS mouth sores, inflammation of the mouth STRATIFY arrange in groups for analysis of results (e.g., stratify by age, sex, etc.) STUPOR stunned state in which it is difficult to get a response or the attention of the subject SUBCLAVIAN under the collarbone SUBCUTANEOUS under the skin SUPINE lying on the back SUPPORTIVE CARE general medical care aimed at symptoms, not intended to improve or cure underlying disease SYMPTOMATIC having symptoms SYNDROME a condition characterized by a set of symptoms SYSTOLIC top number in blood pressure; pressure during active contraction of the heart

TERATOGENIC capable of causing malformations in a fetus (developing baby still inside the mother’s body) TESTES/TESTICLES male sex glands THROMBOSIS clotting THROMBUS blood clot TID three times a day TITRATION a method for deciding on the strength of a drug or solution; gradually increasing the dose T-LYMPHOCYTES type of white blood cells TOPICAL on the surface TOPICAL ANESTHETIC applied to a certain area of the skin and reducing pain only in the area to which applied TOXICITY side effects or undesirable effects of a drug or treatment TRANSDERMAL through the skin TRANSIENTLY temporarily TRAUMA injury; wound TREADMILL walking machine used to test heart function

UPTAKE absorbing and taking in of a substance by living tissue

VALVULOPLASTY plastic repair of a valve, especially a heart valve VARICES enlarged veins VASOSPASM narrowing of the blood vessels VECTOR a carrier that can transmit disease-causing microorganisms (germs and viruses) VENIPUNCTURE needle stick, blood draw, entering the skin with a needle VERTICAL TRANSMISSION spread of disease

WBC white blood cell