Andrew Rider of Insurance Company referred this file for medical case management. Instructions were given to meet with Karen Hartman and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.
INTERVIEW SETTING
On 11/9/16 I met Ms. Hartman at the office of Dr. McPherson. Ms. Hartman works at this medical office so she was already at work. She has not lost time due to her injury. She is alert and oriented and willing to work with a nurse case manager.
MEDICAL FACTORS
Ms. Hartman said she tripped over a cord while at work . She reported she tried to catch herself and hit her left arm. Ms. Hartman did not see a doctor until 11/1/16. She reported she tried to use ice and Motrin.
DIAGNOSIS/DIAGNOSTIC …show more content…
Hartman lives with her husband. She reports her husband is very supportive.
Emergency Contact –Mr. Hartman, husband 989-313-0517.
PHYSICAL DESCRIPTION
Height: 5 foot 4inches
Weight: 207 lbs
Hair: brown
Eyes: brown
Dominant hand: left
CLIENT’S FUTURE PLANS
Ms. Hartman wants to continue to work and heal her shoulder.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Ms. Hartman verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Ms. Hartman denied any legal representation.
IMPRESSIONS
Ms. Hartman reports her overall health is good; she has not lost time from work since her date of injury. The Official Disability Guidelines for a shoulder strain is 34 to 85 days. I have concern that Ms. Hartman is being treated by her employer.
PLAN/ RECOMMENDATIONS
1. Contact Ms. Hartman ever 2 to 4 weeks. Obtain an update on her shoulder pain
2. Attend the follow up appointment with Dr. McPherson on 12/1/16. Obtain a current treatment plan, outcome of physical therapy and address work status.
3. Update the employer after each appointment.
4. Contact Standish Physical therapy for update on therapy and measurable outcome of
INTERVIEW SETTING
On 11/9/16 I met Ms. Hartman at the office of Dr. McPherson. Ms. Hartman works at this medical office so she was already at work. She has not lost time due to her injury. She is alert and oriented and willing to work with a nurse case manager.
MEDICAL FACTORS
Ms. Hartman said she tripped over a cord while at work . She reported she tried to catch herself and hit her left arm. Ms. Hartman did not see a doctor until 11/1/16. She reported she tried to use ice and Motrin.
DIAGNOSIS/DIAGNOSTIC …show more content…
Hartman lives with her husband. She reports her husband is very supportive.
Emergency Contact –Mr. Hartman, husband 989-313-0517.
PHYSICAL DESCRIPTION
Height: 5 foot 4inches
Weight: 207 lbs
Hair: brown
Eyes: brown
Dominant hand: left
CLIENT’S FUTURE PLANS
Ms. Hartman wants to continue to work and heal her shoulder.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Ms. Hartman verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Ms. Hartman denied any legal representation.
IMPRESSIONS
Ms. Hartman reports her overall health is good; she has not lost time from work since her date of injury. The Official Disability Guidelines for a shoulder strain is 34 to 85 days. I have concern that Ms. Hartman is being treated by her employer.
PLAN/ RECOMMENDATIONS
1. Contact Ms. Hartman ever 2 to 4 weeks. Obtain an update on her shoulder pain
2. Attend the follow up appointment with Dr. McPherson on 12/1/16. Obtain a current treatment plan, outcome of physical therapy and address work status.
3. Update the employer after each appointment.
4. Contact Standish Physical therapy for update on therapy and measurable outcome of