Josephine’s Case Study Josephine is a reoccurring patient who struggles with weight issues and an eating disorder. During each session it is important to record certain information for her legal medical records. This information includes
• The dates of her visit.
• Her diagnoses of an eating disorder and her weight issues.
• The reason she is visiting, which is because she wants to remain fit but she is struggling to find a balance between eating healthy and working out appropriately.
• Evaluation of risk factors. Her risk factors at this point are lack of healthy eating, busy schedule and excessive exercise.
• Assessment and treatment. Her trouble areas have been zeroed out and her treatment requires her to visit a nutritional therapist regularly.
• Goals and progress towards goals. After her first session she has agreed to work towards some goals such as, making better food choices, meal prepping, working out appropriately and eating 3 meals with at least 2 snacks throughout the day.
• Signature with the date.
(King & Klawitter, 2007 pg. 272).
Privacy of the medical records remains between Josephine and her counselor. If additional treatment is needed from another health professional, copies of the records may be sent if authorized by Josephine. Although the medical records may be shared it is an option not a requirement (HHS.gov). When closing a session with any client, discussing payment is a conversation that can get awkward quickly. To avoid an awkward
My current view on food is that it creates a sense of comfort and fulfillment, yet this was not always the case. During my teenage years I struggled with an ongoing eating disorder. During that time I viewed food as a threat, or an enemy. As part of my recovery process, I was given a task to make friends with food. I first approached this task with a closed mind, finding a wrong with every meal I ate. My view changed completely when my friends took me out to a vegan diner for a burger and sweet potato fries meal.
I think the doctor will see that she doesn’t weight enough for her height (like before), that her blood work shows that she isn’t getting the right nutrition, and that the blood pressure means her heart isn’t working right (lack of nutrition).
M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.
The purpose of this assignment is to increase self-awareness of the student by analyzing personal nutritional intake and activity routine throughout the course. In turn, the student will be able to help others modify their diet and activity, and improve overall wellness. An examination of a personal food and activity assessment will provide the student with essential data from which to change their health and wellness behaviors.
Per grandmother, the client’s pregnancy, and delivery were normal. The grandmother recalls that Keisha’s developmental milestones were reached appropriately, including basic motor skills such as crawling, walking and fine motor skills such as writing. According to the client, she experienced an accident when she was nine years old. The accident affected her brain causing her to experience a coma for more than a month. It took her several months of rehabilitation to be able to return back to school. Keisha reports fatigue and/or loss of energy very often. Even after sleeping for more than twelve hours per day she feels tired every morning. She has been feeling this way for more than three years. Furthermore, the client reports that she has poor appetite, eating one or two meals per day. Due to her decrease in appetite the client reports that she lost about ten pounds since last year. Keisha mentions that her appetite has decreased since she started high school. Per client, her father abused drugs when he was younger, which included heroin and crack. She is unaware if father continues abusing drugs. Per client, her mother did not abuse any drugs while she was alive. The client reports no allergies, traumas or chronic diseases affecting her
“Patient-specific information recorded and communications made in the course of providing mental health or developmental disability services are considered confidential and may not be disclosed except as provided by law (McWay, 2010, p. 239)”. A patient’s medical record is property of the hospital or the facility that created the record. However, the information held in the record is the possessions of the patient, and a copy of the record (with a mental health or development disability case) can be released to the patient as long as he/she is twelve years old. Also a patient who is twelve years old has the power to consent to release information to a third party. The release of a health record, with a mental health or development disability issue, can be permitted to the patient’s legal guardian without the consent of the patient, if the patient is under the age of twelve years old. However, if a
Throughout this paper you will find that it is going to be discussing many things. Some of those things are to describe a current health problem or nutritional need that I may be experiencing, four nutritional or physical exercise goals, the actions taken to meet each goal, the anticipated setbacks or difficulties and the approaches to overcome them, the outcomes by which to measure success, evidence of the plans effectiveness by addressing the identified problem or need, and the evaluation of potential health risks that may develop if the plan is not implemented. So basically this paper is going to be about a realistic nutrition and exercise plan that best suits me.
A nursing assessment will be presented on Shelby Eatenton along with several interventions and an overall conclusion regarding this patient.
Any information utilized in, “documenting healthcare or health status,” of a patient must be included in the designated record set (AHIMA, 2011). This includes patient documentation collected on any medium, such as WAVE files or x-ray images (AHIMA, 2011). Consequently, due to the incorporation of clinical, administrative, and other protected private health information, the designated record set is extremely different from the legal health record (AHIMA,
General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ): She currently weighs 110lbs. No weight loss. She is well developed and nourished. No distress. States she has always been healthy, other than occasional constipation.
She probably is malnourished and has health complications because of it like low blood pressure and drastic weight loss.
Is her HDL cholesterol level at a healthy range? (2 pts) If not, what dietary patterns and/or lifestyle changes can be incorporated to improve this level. (2 pts per appropriate dietary category)
During our meeting, I asked Lisa and Therese how the facility works overall. Lisa said she checks in the customers at the desk and asks for a complete medical history along with other personal information. She informed me that sometimes patients aren’t comfortable releasing this information in a place where anybody can hear. In order to fix this issue, I think we need to have a more private area where this type of information
Confidentiality and privacy are hallmarks of health care in Ontario. A person’s health information belongs to that person and they have a right to consent to the use, collection and disclosure of that information, with limited exceptions. They also have the right to access their personal health information. Most people are very concerned about their privacy, especially when it comes to matters of their health. Moreover, privacy and confidentiality are cornerstones of establishing trust in the therapeutic relationship between the practitioner and the patient/client. This includes keeping any other personal information about a patient/client confidential. A patient/client who can trust that his/her personal health information is being protected is more likely to provide a complete health history, which would enable more effective treatment (CKO, 2013).
At the outset of treatment, the patient and health care provider should discuss and agree upon goals. The goals must take into account the food habits, exercise behaviors, psychological outlook and support systems of the individual. Realistic expectations, short- and long-term, may be promoted by a discussion of a healthy weight versus an ideal body weight. Features of weight management