Case Note for Homeless Sue: Utilizing the DAP Framework

QUESTION

1) Instructions: Using the acronym DAP (data, assessment , plan) provide a case note for Sue using the following case report:

Homeless Sue, a 35-year-old female, has been diagnosed with Schizophrenia Disorder exhibiting delusions and hallucinations. In addition, she has problems with social environment, occupational problems, housing problems, and economic problems.

Sue is an Iraq War veteran. She served as a liaison to human resources and then as a paramedic. Sue was honorably discharged in 2009. Before she served, she received a degree in medical technology at a local community college. Her father was a veteran and she grew up on army bases. She attended five high schools in four years. Her mother was a secretary and a teacher. She has not seen her family for two years; she lived with them after her return from Iraq, but both parents and Sue could not find a peaceful way to live together.

Sue can often be seen walking to and from the downtown area and the local grocery store. She spends most of her days on the streets. A case manager working downtown saw her walking through the rain and called a friend working for a shelter. She asked if she could refer Sue. The outreach team located Sue during one of her walks the next week.

The outreach worker learned that Sue cleaned up several local businesses late at night. She slept in the places she cleaned. She appeared sober but complained of hearing voices. She believed that she was in danger from wild animals most of the time. She feared for her life; she thought her parents would find her and kill her. Sue had never been arrested. Sue indicated she didn’t want to live in a house and she did not want to live with anybody around. People scared her; noises scared her. She had trouble sleeping.

The outreach worker referred Sue to a local homeless shelter providing comprehensive care. Reluctantly, Sue agreed to come to an initial interview. She asked if the interviewer (who was also a case manager) if they could meet on the streets for the interview. The case manager agreed. After the initial screening, the case manager asked Sue if she would be willing to participate in additional in-depth interviews. She declined, but when each week the case manager encouraged her, she reluctantly said “yes.”

Mental health assessments concluded with a diagnosis of schizophrenia. Sue refused medication. She continues to hear voices, rejects offered housing, but occasionally meets the case manager on the streets. She was willing to be placed on the agency service roles. The service plan for Sue continues to evolve.

ANSWER

Case Note for Homeless Sue: Utilizing the DAP Framework

Introduction

In this case note, we will employ the DAP (Data, Assessment, Plan) framework to document the circumstances and progress of Sue, a 35-year-old female diagnosed with Schizophrenia Disorder, who is currently experiencing delusions and hallucinations. Sue’s situation is compounded by various social, occupational, housing, and economic problems. Her unique background as an Iraq War veteran further complicates her circumstances.

Data

Sue’s background information is essential for understanding her current situation:

Age: 35

Diagnosis: Schizophrenia Disorder with delusions and hallucinations

Occupational History: Iraq War veteran with roles as a liaison to human resources and paramedic

Education: Holds a degree in medical technology

Family Background: Raised on army bases, experienced frequent relocations, strained relationship with parents

Housing Situation: Homeless, sleeping in places she cleans at local businesses

Daily Activities: Spends most of her time on the streets, frequent walks, fear of wild animals and parental threat

Legal History: No arrest record

Assessment

Sue’s assessment reveals the following key points:

Housing Preferences: Expresses a strong preference for living on the streets, fearing people, and rejecting any form of shared housing.

Hallucinations and Delusions: Experiences auditory hallucinations, hearing voices that contribute to her fear and anxiety. She holds delusional beliefs about her parents’ intentions to harm her.

Engagement: Initially reluctant to engage with case managers and service providers, but gradually becomes more open to assistance.

Medication Refusal: Declines medication for her schizophrenia, resulting in persistent symptoms.

Plan

Sue’s service plan aims to address her immediate needs and facilitate her reintegration into a stable living situation while respecting her preferences and autonomy:

Outreach and Engagement: Continue outreach efforts, meeting Sue where she feels most comfortable, such as on the streets, to build trust and rapport.

Comprehensive Mental Health Care: Provide regular mental health assessments and support to manage her schizophrenia symptoms. While medication is the preferred treatment, respect Sue’s autonomy while continuing to educate her on the potential benefits.

Housing Transition: Gradually introduce the idea of safe, single-room occupancy (SRO) housing to address her fear of shared living spaces. Ensure that Sue has a voice in selecting her living arrangements.

Supportive Services: Offer Sue access to supportive services that address her social and economic problems, including job training and employment opportunities that match her medical technology background.

Safety Planning: Collaborate with Sue to develop a safety plan addressing her fears of wild animals and perceived threats from her parents. Connect her with local support networks.

Continued Engagement: Maintain consistent outreach and engagement with Sue to monitor her progress, adjust the service plan as needed, and support her in achieving stability and improved mental health.

Conclusion

Sue’s case highlights the importance of a patient-centered approach when dealing with individuals experiencing complex mental health issues, homelessness, and delusions. The DAP framework helps structure the documentation and planning process, ensuring that Sue’s unique needs and preferences are addressed as she navigates the challenges of her diagnosis and homelessness. Continuous engagement and collaboration with Sue are crucial to her progress and recovery.