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Question: Teresa is a 32-year-old woman in your practice who frequently misses her appointments, and at other times shows up without an pointment, often in crisis. She currently uses alcohol and tobacco, and has started to use street drugs. As you have developed a therapeutic relationship with Teresa, you learn that she grew up in a household with a violent father who frequently assaulted her mother, her siblings and herself. Although now estranged from her father, the impact of his violence presents itself on a daily basis as Teresa struggles to cope with the trauma she experienced. Teresa left school early, has few marketable skills and has never been able to hold a job for more than three months. Teresa receives $606 per month from Ontario Works and has no money left for food or other essentials at the end of the month. She is currently in a relationship with a man whom you suspect may be violent 1. Craft a brief Subject objective assessment plan note that captures her primary concerns, observed behaviors, potential diagnoses, and proposed interventions. 2. Discuss at least four note-taking strategies that can ensure accuracy and comprehensiveness while maintaining the respect and dignity of the patient. 3. Given the recurring nature of Teresa's visits and the potential for long-term care: Describe the importance of maintaining a clear and organized patient record. What challenges might arise in keeping track of such a patient's history over time, and how can healthcare providers overcome them? 4. Taking into account Teresa's volatile personal life and potential risks: How long should a healthcare provider retain Teresa's records considering both clinical needs and legal obligations? Discuss the ethical implications of record retention, especially for patients with histories of trauma and ongoing risk factors. In the context of Canadian law, if Teresa's records were to be subpoenaed due to legal concerns arising from her potentially violent relationship or her own substance use, what are the ethical and legal responsibilities of the healthcare provider in ensuring both patient confidentiality and compliance with the subpoena? Discuss the process and considerations a Canadian healthcare provider should take into account.
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