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Documentation of all patient contact is one of the main responsibilities of a medical social worker. After the initial assessment, a medical social worker must complete a first interview summary case note that provides comprehensive biopsychosocial information, subjective impressions and treatment recommendations.
Presenting Problem The term "presenting problem" is used to describe the reasons the patient was admitted to the facility or decided to come for treatment. During an initial interview, a medical social worker directly asks the patient why he is seeking treatment, if it isn't readily apparent.
The social worker also gathers basic identifying information, such as the patient's age, sex and race. Medical social workers must document the patient's description of the presenting problem as well as try to obtain outside information, if possible, from other involved professionals, such as referring physicians.
The presenting problem is usually written as the first sentence of the case note. For example, you might write, "John Jones is year old Caucasian male presenting for treatment due to a fractured hip.
It focuses on teasing out information that might have a direct impact on the presenting problem. During this process, you obtain detailed information about the patient's medical, psychiatric, social and work history. If the patient is not able to speak for himself, the social worker might need to ask other involved parties, such as family members, for this information.
This information is documented in the case note following the presenting problem. Clinical Impressions and Analysis A first interview case note includes your subjective impressions of the patient, including behavior, eye contact, speech, coherence and mood, and a brief summary of your interpretations of the interview.
For example, after the presenting problem and biopsychosocial information, you would write whether the patient seemed cognizant, engaged, cooperative, energetic or depressed, or anxious. Following this information, you would note any additional subjective information about your interview that would be helpful to other medical professionals reading your case note, such as whether the client appears open or resistant to treatment.
Treatment Plan and Conclusion The recommended course of action, including goals and a suggested course of treatment, if applicable, is the final part of a first interview summary case note.
This section includes information such as referrals to other medical professionals or the steps the patient must take immediately following your interview. For example, you might write, "Referred patient to the psychiatric unit for an evaluation and diagnosis.Strategic planning focuses largely on managing interaction with environmental forces, which include competitors, government, suppliers, customers, various interest groups and other factors that affect your business and its prospects.
A Strategic Planning Template for Dummies This is a very simple template that may be able to assist small business organisations and not-for-profit groups to facilitate their strategic .
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Format email mes-sages, letters, and memos to follow standard business conventions Write clear, courte-ous email mes-sages that are sent only to the appro-priate readers LEARNING OUTCOMES 8 Chapter 8 – Writing Routine Letters, Memos and Emails Paper will always have a use around the office.
There’s really not a lot of difference between a “ one-page business plan” a Lean Plan, and a good executive summary. The only real possible difference is the that the “ one-page plan” must absolutely fit on one page in a font that most people can still read.
Write comments on students' exams. Write brief notes on strengths and weaknesses to indicate what students have done well and where they need to improve.
The process of writing comments also keeps your attention focused on the response.