Reference no: EM133406796

Case: The client is a 38-year-old black female who arrived at the emergency room after attempting suicide. She has a history of depression and anxiety, for which she has been taking medication for the past two years. She has been in therapy for a year but has not been attending on a regular basis in recent months. She has two children, ages six and nine. She has a history of domestic violence and is currently in domestic violence homeless shelter with children. She has estanged family and is high school graduate. She lost her job and evicted from her home.

1. Introduce the client/patient as if you were presenting the person to members of your integrated health care team and/or were writing the first entry about the person in an electronic health record (EHR). Include a brief health history of the client/patient, including information such as chronic health conditions, demographics, and the presenting problem. As relevant, discuss the patient's family members, work/school history, and living situation. Identify at least one screening tool that you can use to further assess the presenting problem or other potential issues for which you might wish to screen or evaluate. Choose a screening tool and include reference why.

2. six functional assessment questions in initial assessment. The questions should address the client/patient's presenting problem. At least one of the questions should be a scaling question.

3. SOAP note (SOAP is an acronym for subjective, objective, assessment, and plan) that would be entered into the EHR that concisely describes your meeting with the client/patient, including your assessment, brief treatment intervention, referrals, and follow-up plan.