4 pages due by 24 hours

PRE-ENGAGEMENT COMMENTS

Indicate any activities that have occurred before meeting with client(s) such as collateral contacts, telephone call with the client, etc.

Medical Social Worker received an SBIRT order for a 36 year old female. No collateral contact prior to our encounter.

NARRATIVE

Record what has transpired between you and your client(s). This should not be a total verbatim report, but a description of observations and the interactions, both verbal and non-verbal. Dialogue should be recorded selectively and when pertinent.

I knocked on the patient’s room door for a verbal response to enter as the patient was sleeping. I met with the patient bedside for an SBIRT request utilizing the AUDIT intervention process. Patient was admitted to the emergency department due to a car accident. Her ETOH level was 602. At the beginning of our interaction the patient was receptive and open to discussion of her alcohol use. Patient reported she had several drinks at lunch with a friend prior to the car accident. She stated, “I don’t drink often and was not thinking about how many drinks I was having”. Patient discussed several times that part of the reason her alcohol level was high was because she did not eat at all during the day. She appeared to be confused and speaking in a lower tone. Patient acknowledged alcohol use impaired her drinking and was a reason that caused the car crash into a pole. She discussed one main trigger for drinking alcohol is stress and anxiety and that’s why she was drinking with her friend to help cope. Patient reported personal coping mechanisms with her stress including yoga as she is an instructor and breathing techniques. At the end of the intervention patient showed resistance to exploring how to further cut down alcohol use as she stated “I rarely drink alcohol”. I offered the patient resources for outpatient substance abuse counseling centers in her community but she declined to accept resources. Currently, the patient is in counseling with a therapist on a weekly basis.

IMPRESSIONS

Describe and discuss your feelings and reactions.

I would have to say I felt uncomfortable during the intervention because it was complicated and shocking. I felt extremely relived no one else was hurt during the car accident. At the end of our conversation I did my best to emphasize her recovery.

By “getting into the client’s shoes”, discuss how you think the client(s) may have experienced both the interview/meeting and your interventions.

I think, the client felt comfortable and traumatized. She appeared to look in server distress and concerned about her actions.

Provide your impressions and/or thinking about the client(s) and your reflections on you interventions in the interview/meeting.

The AUDIT intervention went well and seemed to help the patient understand the possible consequences of drinking alcohol.

PLAN/NEXT STEPS

Patient decided to follow-up with her personal therapist.

QUESTIONS/ISSUES

Indicate questions or specific issues emerging from this interview/meeting that you would like to discuss in supervision.

It was frustrating to accept the patient’s refusal of outpatient or inpatient resources. I think, she was in denial/confused at the moment. Therefore, it was difficult to engage the client of her dangerous decisions.