7.3a Case history

Taking a case history

Taking a case history is one of the tasks of a case manager.

The following case management checklist highlights aspects of the case history specifically relevant for a case history of a person with TBI. So it is important to include all of the following items:

Date of Accident:

This is important for understanding the person’s context. The date of the accident could be an indication of the level of the person’s need for assessments / therapy, support / care.

Period of unconsciousness / Post traumatic amnesia:

This may be an indication of the severity of the injury. It is important to clarify whether or not there has been injury to the brain, as some people refer to lacerations and abrasions to the skull as head injury.

Type of accident:

There are different ways in which a person can sustain a head injury (e.g. car accident, fall, gunshot wound). This can be an indicator for possible compensation.

Rehabilitation History:

A person with a TBI can take a number of pathways through the health system, depending on the severity of their injury. Following acute care:

  • some are discharged home without rehabilitation
  • others go through a period of rehabilitation at different services/hospitals
  • a small number of people with severe injury and high care needs are discharged to nursing homes
  • a small number go to transitional services before moving home alone or with family.

These different pathways can have different implications for recovery, adjustment, and individual perception of needs and types of services required.

Ascertaining each individual’s pathway provides options for accessing additional reports or information about a person’s abilities and disabilities, understanding previous treatment and identifying potential gaps in treatment, or current and future support needs.

People sometimes seek on-going rehabilitation over a number of years. This can be helpful, or it can prolong difficulties in adjusting to the reality of permanent disabilities. Understanding the rehabilitation history helps service providers to make decisions of such requests.

Information sources you can use to assess a person's rehabilitation history include:

  • Agency Reports
  • Self Report
  • Family Report:
  • Others:
Questions to assess cognitive status

Asking these questions can be useful to get a sense of the client’s cognitive status.

Please note: Any of these characteristics could exist due to other reasons. This is purely a guide and in no way a diagnostic tool or indicator of brain injury. However given that someone has sustained a brain injury, these are common difficulties they may experience.

1. Does he/she have problems with day-to-day memory?

2. Does he/she have problems with attention/concentration (eg. while reading a book, watching TV or watching a movie)?

3. Does s/he make a mess of simple tasks they could complete before injury?

4. Does s/he get easily confused when things are explained?

5. Does s/he get stuck on a point and become unable to think or talk about anything else?

6. Does she/he find it hard to change their opinions or their routine, and become easily upset by small changes?

7. Does s/he generate unrealistic plans?

8. Does s/he act before they think?

Level of functioning

This includes:

  • Self care includes dressing, toileting, showering, feeding, grooming and mobility
  • Living Skills includes cooking, cleaning, budgeting, washing, ironing, shopping and independence in the community
  • Work and vocational
Functioning before the injury

It is important to get a pre-morbid history to clarify what changes have occurred since the injury. It is easy to label a person’s behaviour as having an organic basis, but often they are continuing to behave in ways they did before the injury.

Current Social situation

• pattern of behaviour • education/employment • social background • medical issues

Compensation status

Clients may be entitled to compensation, for example third party (CTP), workers’ compensation, sporting injuries or victim’s compensation. Encourage them to seek legal advice from someone with appropriate experience in personal injury claims. Some people miss out on compensation because they get advice from legal practitioners who do not have appropriate experience or knowledge and are wrongly told they are not entitled to compensation.

Other agencies involved

This reveals what assessment or therapy other services are doing and therefore saves duplication.

Case history: Sample

Name:

Date:

1. Period of unconsciousness/post traumatic amnesia (PTA)

2. Date and type of accident

3. Rehabilitation history

4. Types of impairments:

  • Physical
  • Cognitive
  • Personality
  • Communication

5. Level of functioning:

  • Self-care
  • Living skills
  • Work/vocational
  • Behavioral problems (eg. aggression, sexuality, disinhibition)

6. Functioning before the injury

7. Current social situation (accommodation, finance, social supports, current support)

6. Compensation status

7. Other agencies involved