What is a Case History?

| Staff Writers

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A case history basically refers to a file containing relevant information pertaining to an individual client or group. Case histories are maintained by a broad range of professional organizations including those in the fields of psychiatry, psychology, healthcare, and social work. The following information briefly discusses two formal definitions of case histories, the basic contents of case histories, and how the information for initial case history files is obtained.

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Formal Definition of Case Histories

According to the Merriam-Webster Dictionary, the formal definition of case histories is records (or files) containing relevant information pertaining to clients’ environments and history of services. This information is useful in many different fields for the purposes of illustration and case analysis.

Collins English Dictionary provides a somewhat similar definition of case histories. This source states that case histories are records of past problems or events that clients have experienced. It goes on to say that case histories are most often used by professionals in such fields as medicine, psychology, and sociology.

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Typical Information Contained in Case Histories

The type of information contained in case histories may vary depending on the organization that is maintaining the records. For example, while a medical clinic will need to include in-depth medical information about its clients in their case histories, social workers may only need to include more generalized medical information (if any at all).

Instead, they may need more in-depth information pertaining to such things as the client’s history of services, client investigations, or counseling sessions involving the client. In any case, some of the most common types of information often included in case histories are as follows:

  • Basic Statistical Data (Client’s name, age, sex, address, phone number, occupation, marital status, and client ID number)
  • Client’s History of Services
  • Investigations Pertaining to Client’s Case
  • Investigation Outcomes
  • Past and Present Treatments and/or Counseling Sessions
  • History of Illnesses
  • History of Complaints and Their Resolutions
  • History of Referrals

Common Methods Used to Gather Information

There are essentially three methods used to gather information for initial case history files. On the website known as Slideshare, Doctor Surbhi Singh discussed these methods as they pertain to the medical field. However, these same methods can be applied to other fields as well. These methods according to Dr. Singh are interviews and questionnaires (and a combination of the two). A brief description of each of these methods can be found in the following sections.

  • Interviews – By interviewing first-time clients, organizations can gather basic information pertaining to clients’ concerns and lifestyles. They can also determine whether or not clients have used the services of similar organizations, and if they have, they can encourage clients to release this information to them to add to their case histories.
  • Questionnaires – Standardized questionnaires ask many of the same questions that would be asked during a face-to-face interview. This approach is great for organizations that have little spare time to sit and converse with clients. The disadvantage of this method is that some issues may be overlooked.
  • Combination – Combining these two methods is perhaps the best way to gather data for case histories. When organizations use a combination approach, clients are better able to fully explain their histories, and there is little chance of overlooking essential information.

Maintaining complete case histories is an important aspect of providing quality services to clients. A complete case history can help organizations in many different fields determine the best way to serve clients now and in the future.

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