instructions in attachment. due after 8 hours 

Initial Evaluation Worksheet

Date:

Claimant:

CASE SUMMARY:

Place of interview:

Date of Interview:

Individuals present:

Medical diagnosis, status, or reason for case management intervention:

INTRODUCTION:

Sex:

Race:

Age and Date of birth:

Height:

Weight (prior and current if relevant):

Physical appearance (pale, weak, etc):

Sensorium (alert, confused, cooperative, etc):

Signed authorization? (if not, state reason):

MEDICAL:

Recent medical history

Recap of events for this illness only (events leading to point we are at now):

Previous medical care

Prior medical-surgical history, including diagnosis, medications, dates, physicians, outcome:

Current medical status and treatment

Current treatment plan, review of medical record (if indicated):

(What is actually being done medically for claimant at this time, related to current diagnosis):

If appropriate, complete a body system review:

Neurological

Gastrointestinal

Cardiovascular

Urological

Dermatological

Respiratory

Psychosocial

Orthopedic

Endocrine

Physician Consultation

(Summarize the physician-case manager personal meeting or telephone consultation):

Date of contact:

Pertinent Data:

Physical plan of care:

SOCIOENVIRONMENTAL

Family makeup and friend support:

What is family’s apparent understanding and feeling regarding illness and treatment?

Religion notes:

Cultural and language notes:

Description of home and neighborhood:

VOCATIONAL

Occupation:

Education:

Impact of illness on work status:

MOTIVATIONAL_BEHAVIORAL

Claimant’s apparent behavior:

Understanding and acceptance of current problem:

Claimant statement regarding compliance:

Subjective emotional adjustment data:

Psychological issues:

Substance abuse issues:

FINANCIAL

Apparent financial difficulties:

Retired or active employee:

Medicare eligible:

Disability:

Worker’s compensation:

Multiple insurance policies:

SUMMARY AND IMPRESSIONS

State concerns, positive aspects, and case management goals

RECOMMENDATIONS:

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3.

4.

5.

Instructions:

Watch a movie about a person with a significant disability.

Movie  Temple Grandin (Autism/Aspergers)

Complete the Initial Evaluation Worksheet (page 66-70 in textbook).

 Provide the information requested as best as possible. 

If a specific piece of information is not obtainable from the movie, you will need to report what information or assessments you would need to get through your recommendations.

 Do not worry about where it asks hours of case management needed- you can leave that off

Due after 9 hours.