Case Conference Note Template
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Case Conference Note


Prepared By: [Your Name]

Company: [Your Company Name]


Date: March 10, 2061

Location: Bright Futures Rehabilitation Center

Attendees

Role

Dr. Katherine Connel

Lead Physician

Brenda Boyle

Physical Therapist

Jarrett Bailey

Patient

Macey Erdman

Occupational Therapist

Marcelo Green

Social Worker


Patient Overview

Patient Name

Age

Diagnosis

Current Phase

Jarrett Bailey

45

Traumatic Brain Injury (TBI) from a vehicle accident on January 15, 2061

Rehabilitation and recovery

Medical Status

  • Vital Signs: Stable, with regular monitoring in place

  • Medications: Continue with prescribed pain and anti-inflammatory medications.

  • Recent Imaging: MRI shows gradual improvement in swelling and no further bleeding

Physical Therapy Progress

The patient has demonstrated significant improvement in mobility and motor skills since the start of rehabilitation sessions:

  • Increased range of motion in the right arm and leg

  • Enhanced muscle strength observed in lower extremities

  • Effective completion of guided exercises twice daily

  • Challenges noted in maintaining balance and coordination

Occupational Therapy Update

Jarrett has been participating actively in occupational therapy sessions aimed at regaining independence in daily activities:

  • Can perform basic self-care tasks with minimal assistance

  • Working on improving fine motor skills through task-specific exercises

  • Expressed interest in returning to work part-time in the next three months

Social and Emotional Status

Social Worker observed notable progress in the patient’s emotional well-being:

  • Participates in group therapy sessions weekly, showing increased engagement

  • Expresses concerns about a return to normalcy, addressed with coping strategies

  • The support system includes family visits twice a week, proving beneficial

Recommendations and Next Steps

The following plan was agreed upon by the conference attendees:

  • Continued Physical Therapy: Maintain current exercise regimen, focusing more on balance exercises.

  • Advanced Occupational Therapy: Introduce more complex tasks to improve fine motor skills.

  • Cognitive Therapy: Schedule assessment and personalized cognitive therapy sessions.

  • Review Meeting: Set next case conference on May 10, 2061, to evaluate progress and adjust plans as necessary.

Conclusion

Jarrett Bailey's recovery trajectory is promising. The collaborative efforts of the multidisciplinary team are pivotal in fostering his rehabilitation journey. Continuous monitoring and aligned interventions are essential to achieve the goal of restoring Jarrett's independence and quality of life.


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