SCOW 6530 WK 7 Assignment 2: Practice
plan of care, 07-02-2021
Performed by Mrs. S and Mrs. N
Reason for Visit
Care Management
Meeting with client’s parents for update to treatment goals. Concerns: Main room Make bed daily (Mrs.A helps) – change if incontinence issue Daily – Garbage picked up, off of shelves & widow sills, garbage emptied (out of room) Floor swept daily & Mopped if incontinence accident Clothes/shoes picked up and put away Incontinence clothes, sheets, towels, etc washed same day (due to smell) Dust once per week Bathroom Clean weekly shower, toilet, sink, floor Garbage out daily Addition… Open curtains on sliding door each morning and close them at night. Needs to be bright and not cave-like Discussion about B and T ( AFH care givers) assisting with client’s care. Family in agreement. Switched PCP appt to Wed July 7th @ 2:30pm- T will attend with client. Updated on legal separation details. Discussion about client going to church with family- how to support/address attention seeking behaviors/accusations. Visit time: 1 hour Plan: Notify AFH owner of requests Physical therapy
Assessment & Plan
Last Reviewed Date 07/02/2021
General Plan Note:
Treatment planning includes:
*Private Therapy to address past trauma and ongoing anxiety/depression with VP counselor, Jenifer
*Assistance with Advocating for self
*On-going medical care with PCP
*Increase coping skills
*Reduce attention seeking behaviors
Family Values
• Safe plan for appropriate interactions with friends.
• Good supervision and responsiveness from Care Manager who will oversee the plan
• Medical evaluations of medications and diagnosis
• Continued communication and planning with CM
• Budgeting-have checks and balances on spending
• Address depression and get her socializing appropriately
• Nutritional evaluation to optimize her health
• Exercise program for balance improvement- Physical therapy
Acuity level: Level 2- Lives in AFH. Good support, but relies heavily on CM for medical needs & has counseling needs
*****CM has weekly interaction per client’s request. CM available if needs arise. ***************
Issue #1: Behavior and Mental Health
Assigned to/Managed by: Care Manager
General Notes: Creating and maintaining appropriate social relationships
No interaction with E or C family members
Recommendations:
1. Care Manager Coaching:
Mrs. A to work closely with Care Manager and Therapist to address labile mood
Cooperate with Trustee on identified needs
Finding avenues to pursue purpose and ways to help in community
Specific Tasks/To Dos:
1.Be safe and emotionally stable in home
2.Cooperation with ongoing Care Management coaching
3.Cooperation with forward movement
4. Emotional Regulation
Issue #2: Behavior and Mental Health
Assigned to/Managed by:Care Manager
General Notes: Needs Private DBT therapy for ongoing emotional needs
DBT skills include skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness
Psychiatrist assessment needed for medications – Completed
Updated needs: Continue to participate in treatment recommendations.
Recommendations:
1. Care Manager to identify appropriate treatment options
2. Assist with scheduling and coordination of treatment
Specific Tasks/To Dos:
1.On-going participation with treatment providers
2.Improvement in emotional wellness
3.Engage in Intensive DBT
4.Appropriate medications and take as prescribed
Issue #3:Medical Health
Assigned to/Managed by:Care Manager
General Notes:
Client has recently established care with new PCP- Tina Siridakis, ARNP. 2019
CM will continue to assist with follow up appointments
Update: 09/2020- Client established care with Naturopath- Veronica Skedd, DO
Recommendations:
1.Care Manager will coordinate all of client’s medical and therapy appointments :
Update 7/29/19-
Follow up PCP appointment
Eye Exam
Dental Exam
Update 11/21/19 client is compliant with medical care. CM working on dental insurance
Update 1/13/20 Waiting on ultrasound results. Scheduled visit for prosthetic
Update: 10/2020 GI consult, Pelvic & Liver ultrasound
Update: 4/22/2021- OBGYN consult needed
Specific Tasks/To Dos:
1.Overall improvement in health and wellness
2.Continued compliance with medical appointments and recommendations.
Completed Issues/Recommendations:
1. Medical Health
Archived On: 6/5/19
Notes: Mrs. A does not currently have a primary care physician. At this time most of her care is provided through Urgent Care and Emergency Rooms.
Update: Will arrange PCP once permanent residence is decided. Currently sees MD at PCH for medical needs.
Update: 5/15 PCP appointment May 16th @ 1 pm
Goal(s): Mrs. A will have a primary care physician for short term and long term medical needs.
adult health examination
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