Reference no: EM133715737

Assignment

Overview:

You are ready to discharge your first client as a case manager. You will prepare two documents: a termination letter to be sent to your client Sue and a discharge summary for the client file. You can elaborate on the given information to complete this assignment. Using your imagination, you decide why Sue was discharged, her progress, and any pertinent follow-up recommendations.

Instructions:

I. Termination Letter

A. Apply the information provided in the Case Vignette as well as your Case Plan Assignment to complete your termination letter.

B. Your termination letter should be addressed directly to Sue and will summarize the following points:

1. Reason for termination (did the client complete treatment goals? Have you been unable to get in contact with the client? Are you leaving the agency? Is your client no longer interested in services?)

2. Summary of your work with the client

3. Summary of goals achieved

4. Follow-up required by the client (i.e. medication management, other services, etc.)

II. Discharge Summary

A. The discharge summary is a professional note that will be placed in Sue's file and may be maintained in agency records or sent to other providers.

B. Your discharge summary should include the following:

1. Client name, DOB, date of admission, and date of discharge
2. Diagnosis (if there is one)
3. Any medications that were prescribed
4. The reason for discharge
5. The major presenting problem that brought the client to you
6. The client's goals and objectives
7. Progress that was made or goals that were accomplished
8. Problems identified but not addressed

1) How the individual appeared to be (presented) at intake and again at termination
2) Attempts to locate the person if relevant

Sue Hernandez, a 35-year-old female, has been diagnosed with Schizophrenia Disorder exhibiting delusions and hallucinations. Sue identifies as a white, Hispanic, straight woman who has never been married. Sue is an Iraq War veteran. She served as a liaison to human resources and then as a paramedic and was honorably discharged in 2009. Before she served, she received a degree in medical technology at a local community college. Her father was a veteran and she grew up on army bases. She attended five high schools in four years. Her mother was a secretary and a teacher. She has not seen her family for two years; she lived with them after her return from Iraq, but both parents and Sue could not find a peaceful way to live together. Sue can often be seen walking to and from the downtown area and the local grocery store. She spends most of her days on the streets. A case manager working downtown saw her walking through the rain and called a friend working for a shelter. She asked if she could refer Sue. The outreach team located Sue during one of her walks the following week and learned that Sue cleans up several local businesses late at night. She sleeps in the places she cleans. Sue appeared sober but complained of hearing voices. She believes that she is in danger from wild animals most of the time. Sue also often fears for her life and believes her parents will find her and kill her. Sue has never been arrested and indicates she doesn't want to live in a house, and does not want to live with anybody around. People and noises scare Sue and she has trouble sleeping. The outreach worker referred Sue to you, a case manager at a local homeless shelter providing comprehensive care. Reluctantly, Sue agreed to come to an initial interview.