Free Support Worker Case Note Template
Support Worker Case Note
Prepared By: [Your Name]
Company: [Your Company Name]
Client Information
Client Name: Cyrus Ortiz
Date of Birth: March 15, 2025
Reference Number: C2061-0034
Address: 1234 Elm Street, Metro City, Region A
Date and Duration of Visit
Date: August 14, 2061
Time: 10:00 AM - 11:30 AM
Purpose of Visit
The primary objective of today’s visit was to assess Cyrus’s progress post-surgery and to update the ongoing support plan. This involved discussing his medical rehabilitation, reviewing medication compliance, and evaluating his emotional well-being to ensure a holistic approach to recovery.
Observations and Findings
Physical Well-being
Cyrus appeared well-groomed and in a positive state of health. The following observations were made:
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Healing incision site on left shoulder observed; no signs of infection.
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Reports minor discomfort managed effectively with prescribed analgesics.
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Cyrus can perform basic movements with limited assistance.
Emotional and Psychological Well-being
Cyrus maintains an optimistic mindset post-surgery but reports occasional feelings of frustration related to physical limitations. The following points were discussed:
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Encouragement to express feelings and participate in support groups.
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Weekly sessions with counselor, scheduled every Friday.
Medication and Treatment Plan
Cyrus is compliant with the prescribed medication regimen. Current prescriptions include:
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Pain Relief: Paracetamol 500 mg, twice daily.
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Antibiotic: Amoxicillin 500 mg, three times daily for one more week.
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Physiotherapy Sessions: Attending twice weekly to improve mobility.
Recommendations and Next Steps
Based on today’s review, the following recommendations and actions have been agreed upon:
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Continue current medication and physiotherapy schedule.
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Engage with local support group every Wednesday evening.
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Next follow-up appointment scheduled for September 11, 2061.
Communication with Other Professionals
Contacted Cyrus’s physiotherapist to review latest progress and coordination:
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Physiotherapy assessment indicates steady improvement in mobility.
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Plan discussed for incorporating light resistance exercises in the next session.
Consent and Confidentiality
Cyrus has provided consent for his health information to be shared with relevant healthcare providers involved in his care under strict confidentiality guidelines.
