SERVICE EVENT
Service Date and Time: 07-Dec-2018 1536PST - KLOTZ, JANET
SURF Type of Contact: DF = Direct face-to-face
PROGRESS NOTES
Subject: GSS-MHSu-Victoria-RN-Progress Note
Progress Note: Background:
This client was admitted June 29, 2018 and discharged August 27, 2018. ... Writer recieved [sic] a referral to see the client post discharge. Writer attempted to see the client and agreed to a visit [— Redacted by FOIA derps by virtue of FOIPPA s22 'disclosure of personal information is presumed to be an unreasonable invasion of a third party's personal privacy...'—] After many unsuccessful attempts to gain access through Isaac, writer spoke to Susan Barr and it was determined that writer should close the chart. Please see my prior documentation.
December 5, writer recieved [sic] a call from the client. She stated that she had fallen a month ago and broken her wrist. She stated that she needed some help with her walker. Due to the language barrier it was difficult to determine exactly what client was saying. Writer explained that client should call community access to generate a referral to be seen. Client stated she could not write down the phone number. With some encouragement the client agreed to get her son David on the phone. [— Redacted by FOIA derps by virtue of FOIPPA s22... —] He agreed to call community access. A referral was then recieved [sic] for Physiotherapist from the client's S-I-L, Isaac. Referral stated that as per Isaac, there was to be no call to the client or son and that Isaac was to be present for the home interview via Skype.
Writer spoke to Susan Barr and it was determined that staff should deal directly with the client. Jennifer PT phoned the client and she agreed to a visit today, December 7. Writer and Jennifer did a home visit.
The client buzzed us in. the client lives in a one bedroom apartment. Writer noted that there was a pot simmering on the stove and raw chicken sitting on the counter. The client stated that she does not cook and that her son David does all the cooking. [— Redacted by FOIA derps by virtue of FOIPPA s22 'disclosure of personal information is presumed to be an unreasonable invasion of a third party's personal privacy...'—] The house in general was very cluttered with boxes, garbage and other items. The carpets were soiled. The client is sleeping on a bed in the middle of the front room. English is not the client's first languae but she was able to communicate fairly effectively. She showed writer the pills that she was taking which were some vitamins and she stated that she had taken 3 advil but they made her dizzy so she was not taking any more. The client also showed writer a bottle of tylenol sinus that she thought was for pain. She continually spoke of infection. She then pulled out some blister packs that had only been partially accessed and were dated August of this year. She stated that she had stopped taking them in November because they made her feel bad. She showed writer inhalers that she had been prescribed but was not using. The client stated that she was taking her cast off at times and that her hand would then hang limply. She stated that the last few nights she had been in so much pain that she couldn't sleep. [— Redacted by FOIA derps by virtue of FOIPPA s22 'disclosure of personal information is presumed to be an unreasonable invasion of a third party's personal privacy...'—] The client also spoke of sutures in her groin and spoke of a man pulling a baby out of her and her bleeding. She stated that mosquitoes were going into her eyes and also into her cast. She stated that this really scared her. Writer explained to her that she needed to have her wrist assessed due to her increased pain and that she had been taking her cast off. The client agreed to do so. [— Redacted by FOIA derps by virtue of FOIPPA s22... —] we stated that the client was going to the hospital. Client was accompanied by writer in the cab and report was given to Liason. [— Redacted by FOIA derps by virtue of AGA s46... —]
Klotz, Janet - 07-Dec-2018 15:36 PST
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