Case Management Progress Note

Case Management

Progress Note

Client: _____Samantha_________________________

ID: _______________________________________________

Date: _____03/12/2021_____________________________

Need(s) Address:

The client’s needs include the inability to stop the usage of methamphetamines, food insecurity in the household, unsafe environment for children, and neglect and lack of supervision for the children.

Summary of Actions:

The case manager referred the patient to a support group to help with motivating the patient to stop the use of methamphetamines. The CM also referred the patient to a therapist who would use cognitive behavioral therapy to identify the patient’s triggers for the usage of drugs. The CM also recommended the use of pharmacological methods to help with the withdrawal symptoms associated with the cessation of drug usage. Employment resources were provided to increase the household income to enable the client to afford food for herself and her children. Education was provided on the many potential hazards present in the household that may affect the children’s safety. The client was also educated on the need for regular child supervision.

Results of Action Steps:

The client has started seeing a therapist. She reports that she has identified some of the thoughts and triggers that drive her to use drugs. The client has also started attending local support groups for drug addicts. She reports that she still hasn’t found the courage to share her drug experience, but she’ll get there. The patient has also applied for food relief and food subsidies. The client has been actively applying for jobs but hasn’t been successful in getting a job yet.

Next Steps and Responsibility Party

(include the date and time of the next visit)

The client will meet with the CM after two weeks on 17/12/2021. The client will also continue seeing the therapist as well as attending the local support groups. The client will continue applying for jobs.

Signature: _____________________________ Date: _____03/12/2021__________________

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Question

Case Management Progress Note

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Using the vignette, please complete the Case Management Progress Note.

Samantha is a 30-year-old Hispanic female who has just lost custody of her two children (ages 3 and 5). Child Protective Services (CPS) became involved after a neighbor reported concerns of neglect and substance use by Samantha. Samantha confirmed regular use of methamphetamine, though she reported wanting to get help for her children. CPS also found that there was limited food in the home and other safety concerns. The neighbors also reported the children were often outside for extended periods of time without supervision. The children have temporarily been placed in a foster home.

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