bio-psycho-social assessment In this assignment, you will conduct and write a bio-psycho-social-spiritual assessmen University of South Carolina
College of Social Work
Field Education Office
781 Process Recording Template
Date: 11/06/2021 Name: Lou Sorrells Agency: Amedisys
1. Client System: Mrs. Rivers
2. Presenting Issue (s): Regular Visit
3. Purpose: Interview/ Observation: Observation/Interview
a. Content of Contact
observations of client(s) and self (external)
c. Student’s feelings,
d. Competencies Demonstrated or need to work on what competencies or skills sets. Identify needed growth
Client name: Ella Rivers
Currently living at home
Field Instructor: Mrs. Angela Scott introduced me to the Client.
Client seem happy to see field instructor and intern student
I was excited to meet the client, heard so much about her and what a hard worker she was
Worked at the school district for approx 30 year.
Hello Mrs. Rivers I brought someone to meet you today. I was telling her about your long time employment with the school district.
Hello Mrs. Rivers my name is Lou Sorrells and I’m Mrs. Scott’s Intern nice to meet you.
Client started to tell the field Instructor and new intern student of her years of working at the School I District for so many years. .
Feeling more relaxed talking with client.
Ethical and professional boundaries
Lou did a good job in introducing herself as an MSW intern and her role as a student within the Amedisys team (always important to identify yourself to the client especially when first meeting them)
How have you been Feeling?
Client: I’m feeling pretty good it’s just this right feet and leg that’s taking a long time to heal.
I know you’ve been getting around a lot more using your walker.
Client: Yes, moving slow but I’m getting around ok.
Client is relaxed speaking with field instruction and Intern
Overwhelmed by the attitude she had with school student
Has the swelling been continuous?
Client: yes, the doctor doesn’t think the circulation is good.
Client was rubbing her leg as if it may be painful
Mrs. Rivers is still mobile and memory seems to be very well.
Building trust and rapport
Initially Lou was reserved and did not interject but as she became comfortable she began to engage in conversation(This is Lou’s first client she now sees on a regular basis)
Has the doctor given you special instruction for the care of your leg?
Client: Yes, he said I need to keep it elevated as much as possible.
So Mrs. Rivers how is that working for you
Client: I try keeping it elevated but it doesn’t allow me to do things like I use to.
Mrs. Rivers it’s ok to take more time to help yourself.
Mrs. Rivers was very informative about the care of her right leg, also explained to us the nurses instruction after coming out to visit with client.
Mrs. Rivers has a CNA that comes in to help with bathing/ dressing for safety reason.
Engage, assess, intervene, evaluate
Lou demonstrated empathy towards clients and verbalized importance of safety (pt self-determination) as patient resides alone however her son reside next door and patient has life alert; pt has the capacity to use the telephone
Mrs. Rivers is there anything we can assist you with or do you need anything.
Client: No, supplies came yesterday so I’m good.
Do you need assistance going to the rest room?
Mrs. Rivers also voice concerns about COVID 19 and being hospitalize and how she sometimes can’t remember things clearly at times.
Mrs. Rivers is a very family oriented person and enjoyed telling story about her days with
How are your children doing?
Client: there find my daughter and son come by after work each day.
II know that must be nice visiting with them.
Mrs. Rivers is very proud of her children and grand’s.
Patient support system along with her religious beliefs has helped patient to be stabilize and reside in her home independently
Have you been eating and sleeping ok.
Client: Yes, I sleep well like I said it’s just that swelling in this leg that won’t go away so It can heal from surgery
Mrs. Rivers expressed her how good
Mrs. Rivers we’re going to leave are you sure you don’t need anything from us before we leave.
Client : No thank you I’m good
It was really nice meeting you Mrs. Rivers will be back to see you next week
Mrs. Rivers was very happy with her visit with us, she seems to enjoyed our interaction with Hospice
Lou did a good job for her first time with this client she was able to demonstrate rapport building, respect of client views and self – determination, Identified safety awareness and offered assistance
Interpret the interview:
Include detail about the tone and climate of the setting, your initial impressions of attitudes and feelings of the client, what attitudes and feelings you brought to the interview, what significant changes in the client occurred during the interview in terms of appearance, gestures, and posture?
Analyze why you think your interaction with the client unfolded in the manner it did. What is your assessment of your client’s reaction(s)? Reflect on the strengths and weaknesses of your intervention and identify an area you would like to improve upon for your next session. Note at least three questions to bring to your next supervision with your field instructor.
The climate of my setting was at the house of the client who was in hospice care .lovely brick home with car port, No car noted but large yard That could use some work but beautiful area. My idea plan was to go and introduce myself and get to know the client and conversant about her many years of employment with the school district. I wanted the client to understand that I also worked for the state for 15 years who is interning at hospice so that she would feel more relaxed. The impressions of attitude that I had towards the client were that I was not expecting her to be so vibrant and so calm and collective about her approach towards me. I saw that as I was introducing myself, she seemed to be more focused on checking me out and seeing was I just another person coming to her house from the agency. The feelings that I had was empathy and compassion for this retired state employee who has worked for great state and now is had suffered from a COVID 19 along with other medical Issues. I did notice how the client did respond to the initial introduction of me telling her that I was an ex state employee her demeanor changed and she begin to show more of a dedicated focus to me. The appearance of the client despite her condition seemed to be in good spirits. The client never showed any signs of suffering. The client started to focus more on the conversation and was more engaged on my knowledge of certain things that she could use to assist her. My strength is that I love to talk to clients, and I have a particular skill set to adapt to any client situation. My weakness is that I try to help anyone that I can when I have the means to, but sometimes things do not always go as planned.
1. What is the feeling that you feel after you have done all that you can for a Hospice client?
2. How do you respond to a client whose homes are in need of proper health equipment?
3. What’s the hardest thing for you as a social worker to deal with a client?