Lifecare Project Essay

1720 words - 7 pages

Running Head: LIFE CARE PLAN LIFE CARE PLAN PAGE \* Arabic \* MERGEFORMAT 8
Becky TalleyBSN 440, Assignment 3American Sentinel UniversitySeptember 27, 2014"A Life Care Plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research, which provides an organized, concise plan reflecting current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs" (Weed and Berens, 2010).Health care planning is a comprehensive assessment of a patient's health concerns where a problems or a list of medical diagnosis generated. Problems can range from medical condition to relationship problems that affect the overall well-being of an individual. Once the problem list or medical diagnosis has been identified goals are developed that are specific to the medical condition, measurable and attainable. In order for each goal to be meet they must be realistic to be measurable. If a patient suffers from a chronic medical condition that is irreversible the goal would be to help maintain his/her health at the most optimum level as possible.In the following Life care plan, I have chosen to continue provide a health care plan that extends outside of the emergency room setting. The goal of this plan is to guide all who are to be involved in the care of A.S. so that appropriate treatment can be given.Life Care PlanPrepared For:A. S.

Certified Disability Examiner:

Rebecca Talley, RN

Life Care PlanReportRebecca Talley, RNSUMMARY PAGE
NAME:

A S

SOCIAL SECURITY NUMBER:

123-45-6789

DATE OF BIRTH:

07-28-1950

DATE OF ONSET:

2 weeks

DATE OF EVALUATION:

09-20-2014

DATE OF COMPLETED REPORT:

09-26-2014

TOTAL TIME (Interview/Record Review, Care Plan Consultations-Research, etc.):

60 minutes

DIAGNOSIS:

Axis I: Major Depressive Disorder, Recurrent, Severe
Social Anxiety Disorder
Rule out generalized anxiety disorder
Axis II: R/O Avoidant Personality Disorder
Axis III: Migraine Headaches
Axis IV: Mild: Having difficulty going to school and considering dropping out
Axis V: GAF=55

MMI:

N/A

IMPAIRMENT RATING:

N/A

PHYSICAL DEMAND LEVEL:

N/A

Life Care PlanReport
Referring Party:

None

Evaluation Location:

,

Examinee:

A S

Date of Onset:

2 weeks

Date of Evaluation:

09-20-2014

Medical Intake/History ReviewPatient suffering from increased depressive mood and anxiety after unable to obtain appointment with current psychiatrist.
MEDICAL RECORDS PROVIDED BY: none provided

,

MEDICAL RECORDS REVIEWED:R. Talley, RNDr. F. A.CHIEF COMPLAINT AND SUBJECTIVE HISTORY OF PRESENT INJURY BY PATIENT:"I just feel overwhelmed and can't take it anymore" A.S. is a 22 year old female who reports feeling depressed and difficulties with increased anxiety. Patient states that her symptoms began at the age of 13. She started counseling at the age of 14 but never followed through and became...

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