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Clinical Vignette Part 1

Two parts of a clinical vignette are to be developed that are the basis for the final cumulative paper. Select a person whose sub-culture is different from your own. If you do not have a current practice case, it is possible to use a case from past practice, literature, or film. However, if you do the latter, discuss this with the instructor. Danny’s case example cannot be used for these assignments, as he will be thoroughly discussed during the semester in other activities.Part 1 (worth 10 points) includes:Introduction: Explain your role with the client and in what context you work with this person.Identify data sources for the report and source of the referral.List the Identifying Information (name [use an alias], age, gender, race, sexual orientation, nationality, religion, relationship status, children, ordinal position in family of origin [e.g. oldest, youngest, only child, etc.], education, socio-economic status, occupation, current employment). Identify any missing information.Presenting Problem: This provides a concise description of the presenting problem (what was the problem when the person presented for services?).Chief Complaint: As stated in client’s own words or present a summary of the client’s view of the situation.Describe the history and context of the problem situation.Brief history of psychosocial factors and family history (could be 2 – 4 pages depending on the information available) – details on the Rubric below.Develop a list of current diagnoses and include current medications.State whether you agree or disagree with the person’s current diagnosis and why.


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