Documents included in the case file
Donna is 26 years old and in her fifth month of pregnancy. She is visiting a health clinic that provides for prenatal care for the first time. In addition to prenatal care, they provide comprehensive “wrap around services”. The medical workers provide details to clients on prenatal care, nutritional counseling, and prenatal vitamins. The initial assessment of her pregnancy is as “progressing normally” at this stage. She was referred to you because she indicated that she consumes one to two drinks almost every day after work. She sees this as a way to unwind at home from the stress of her job. She also has anxiety about being a single-mom. There are also social events on weeknights and weekends with family and friends that typically involve light to moderate drinking.
Describe the documents that you may want to include in the case file. From the case file documents, identify ways to detect mental, behavioral, or emotional issues for a client. Review the case scenario, which documents would you include in the case file for this client? Why?