CM normally meets with the client for face to face meeting on Friday. On 4/14/2016, CM met with the client to complete Bi-Weekly ILP Review because client has an appointment scheduled at Wyckoff Wound Clinic. In the meeting client reported she was discharged from Wyckoff Hospital on 4/11/2016, due to her lymphoma and open ulcer wound. She also reported she has follow up medical appointments. During the meeting client had a head wrap around with a beige scarf and knit hat.…
CCIB Intake received a SOC 341 from reporting party Donna Meekins Kaiser Home Health Social Worker/Case Manager (626) 826-6993. The reporting party stated that resident Louis Morales DOB: 8/26/46 has dementia with behavioral disturbance and resides in the facility where he has easy access to leaving the facility. The reporting party stated the resident is a health and safety hazard to himself. Subsequently there are no safety locks to prevent the resident from leaving the…
UCM:CPSW did a home visit on 12/28/16 to met with Kaison and the foster providers (GeorgianneSpeliopoulos & David Luker) Kaison seemed happy and learning to walk without any assistents. to check on Kaison and the foster providers has any concerns. CPSW asked about Kaison daily routines. The foster provider reported no concerns.…
On 8/8/2017, CM met with the client to complete Bi-Weekly ILP Review. CM inquires the reason client was no show for her previous face to face meeting. Client reported she had a doctor appointment. Client in the meeting was wearing a short pant and a t-shirt. She was well groomed.…
D- Client arrived on time with her child, Fiona, for her scheduled appt. with this writer. During the course of the session, this writer and the client discussed a recent fax sent by the client’s PCP about the client hx Hep. C.…
Circumstance: CSP made face to face contact with MHS and Juliet to monitor Juliet’s well-being. Action: CSP and MHS discussed Juliets’s recent medical visits and contact with DSS worker. MHS explained Juliet’s WIC appointment was good. Juliet’s weight was not checked. The youth will continue on the same formula.…
Mr. Chavis is a 24 year old male who presented to the ED via LEO under IVC through DayMark Recovery Services. Per documentation Mr. Chavis presented to DayMark Recovery Services with suicidal ideation, stating he wants to die and plans to do it soon. He reports in the past week cutting himself uncontrollably, making multiple lacerations to his right arm. In addition, Mr. Chavis engaged in pathological substance abusive behaviors. At the time of the assessment Mr. Chavis is calm and cooperative.…
A phone call was held with Mr. Cornelius, Naisha Lawrence and Kim Drayton. The purpose of the phone call was to discuss the issues regarding Christopher therapist Melisa Davidoff. Mr. Cornelius is requesting that he has an open line of communication with Ms. Davidoff. Mr. Cornelius stated that the issues with Christopher's therapist aroused from a statement made during visitation with Peaceful Measures as Michael Stephen and Christopher were returned home after visiting with their dad. Mr. Cornelius stated that as the boys was returning from a visit with him, Christopher attacked his mother.…
On 7/5/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client appears to be upset and distraught. Client mood was un-balanced and her affect was in- appropriate. Client denied suicidal or homicidal ideation. Client was dressed with proper attire for the weather.…
Diana is a 21-year-old Hispanic Female, single, never married who presents to CRU 1 from Abrazo Maryvale Campus. She is admitted voluntary, T19, and GMH. Patient lives with parents and two younger sister. She is seeking psy. inpatient treatment for SI.…
Patient is a 42-year-old male who presented to the ED with an alleged overdose on 50-60 prescribe pills of 450mg PO Daily Trileptal. Patient stated: "I took pills because I was having mood swings." Step- father brought patient into the ED. At the time of assessment, patient endorses feeling suicidal without a plan. Patient reports not being able to go see his son as the primary factor contributing to his current distress.…
The claimant was a 58-year-old man. Alleged disability: Chronic fatigue, Epstein Barr syndrome, fibromyalgia, degenerative disc disease, irritable bowel disease. He reported that he currently was a pastor and was able to work depending upon his energy and pain levels. Education: Four or more years of college (1990). Work experience: Financial representative (financial institution (1997-2004), communication coordinator (religious organization 2004-present), and customer service (retail store 2014-2016).…
With respect to the abovementioned, the therapist should consider disclosures, authorizations, and a written release of information to obtain Steven’s medical records from his PCP, to coordinate care. Especially since he got dizzy while driving and experienced the inability to breathe at the mall, helps the therapist understand if a possible medical condition exists or rules out the possibility that his symptoms transpired in part of a medical condition. Not to mention, the PCP could have prescribed Steven some medication in the interim, unbeknownst to the therapist. Thus, knowing whether Steven’s symptoms were attributable to any biological effects of a substance/medication is paramount.…
Finally I asked a close ended question and discovered that the patient drank alcohol. This was where the health history became very interesting. After asking her about her alcohol intake, I was shocked beyond belief to find out that my patient was an alcoholic. This was the most significant factor in my interview, considering that she is 60 years old. At this point I had figured it all out.…
During the interview, the home environment was quiet with no distractions which made it appropriate for an interview. By conducting the interview within the family’s home, I also got a look at interactions among family members and to look at the status of the home and neighbourhood. Melissa, being a Licensed Practical Nurse, was knowledgeable and understood many of the chronic conditions, allergies, ilnesses etc. of her family members off hand, which made the interview process run smoothly. Melissa and her family were also very open to me coming and doing the interview, they were very welcoming and friendly.…