Pcp Case Study Examples
G: CM met with client for weekly case management and to complete intake.
I: CM assisted client with completing intake process (HOMES) .CM used open ended questions to continue building report with client. CM inquired about the client’s next medical appointment with his PCP. CM also inquired about the client’s ongoing skin condition. CM praise client for being on time to the meeting and for being honest regarding his drug use. CM encouraged client to continue to stay motivated within the program. CM continued to assess for PTSD symptoms, substance abuse, and medication compliance.
R: Client presented well groomed and his skin condition continued to appear improved from the previous weeks. His mood and affect were appropriate. The client appeared calm and made good eye contact, was cooperative, and open for discussion. Client reported having a medical appointment …show more content…
Client reported using heroin (IV) at least 15 times within the last 30 days. Client stated that he often uses heroin when he is bored. Client reported being careful and cautious not to share needles when shooting up heroin. Client stated that he continues with his methadone maintenance program.
Mental health: Client reported having nightmares secondary to PTSD. The client described waking up sweating after having intense nightmares in the past. Client reported being open to receiving MH services through his Opiate Treatment provider. The client also reported being open to joining a PTSD support group while in the program. Client denied having any S/I and H/I at this time.
Financial: Client reported his continued desire to participate in the program's savings plan starting the first week of February. Client currently receives disability compensation in the amount of $836 each month, along with $64 from SSI. The client reported his desire to contribute $400 dollars each month to his saving’s
I: CM assisted client with completing intake process (HOMES) .CM used open ended questions to continue building report with client. CM inquired about the client’s next medical appointment with his PCP. CM also inquired about the client’s ongoing skin condition. CM praise client for being on time to the meeting and for being honest regarding his drug use. CM encouraged client to continue to stay motivated within the program. CM continued to assess for PTSD symptoms, substance abuse, and medication compliance.
R: Client presented well groomed and his skin condition continued to appear improved from the previous weeks. His mood and affect were appropriate. The client appeared calm and made good eye contact, was cooperative, and open for discussion. Client reported having a medical appointment …show more content…
Client reported using heroin (IV) at least 15 times within the last 30 days. Client stated that he often uses heroin when he is bored. Client reported being careful and cautious not to share needles when shooting up heroin. Client stated that he continues with his methadone maintenance program.
Mental health: Client reported having nightmares secondary to PTSD. The client described waking up sweating after having intense nightmares in the past. Client reported being open to receiving MH services through his Opiate Treatment provider. The client also reported being open to joining a PTSD support group while in the program. Client denied having any S/I and H/I at this time.
Financial: Client reported his continued desire to participate in the program's savings plan starting the first week of February. Client currently receives disability compensation in the amount of $836 each month, along with $64 from SSI. The client reported his desire to contribute $400 dollars each month to his saving’s