Location: Emergency Room SUBJECTIVE: This Is a 38-Year-Old Female Who Presents to the Presents

question 57

Short Answer

Location: Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.
OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.
PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.
CPT Code: ____________________

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Definitions:

Generalist Intervention Model

A framework in social work that applies a broad range of skills and techniques to address problems.

Engagement

The process of establishing a trusting and collaborative relationship between the social worker and the client, which is crucial for effective intervention.

Assessment

A process of evaluating or determining the nature, condition, or importance of something, often used in professional settings to identify needs or performance levels.

Power Issues

Concerns related to the distribution, exercise, and effects of power within various social, political, or organizational contexts.