The following samples provide examples of documentation a case manager might find helpful when attempting to create a profile of an individual's disability:
Please note that the following samples from a summary report letter are excerpts. They are provided here as an example of each section, not as a rendering of a complete letter.
Ms. Amelia Smith is a 35–year–old woman who has a lengthy history of bipolar disorder, hypertension, diabetes, and homelessness. Ms. Smith is 5'5" and weighs 195 pounds. Her hair is matted and often dirty. She has had little dental care and is missing several teeth in the front of her mouth. She dresses in several layers of clothes despite the weather and has a strong body odor most of the time. In conversation, Ms. Smith either speaks very rapidly and is difficult to re-direct or she sits in long periods of silence. In either state, she seems to have difficulty following questions and responding to them appropriately. When depressed, she moves extremely slowly and appears very sad. When speaking rapidly, she becomes easily irritated if interrupted and then refuses to continue with the conversation.
Most of Ms. Smith’s history is contained in submitted medical records. However, her history of sexual abuse is not mentioned as she has not discussed this in treatment in the past. Ms. Smith reports that, from ages 8–13, her maternal uncle, who lived with the family, would come in her room at night and touch her “in private places” and make her “touch him.” She was afraid to tell her mother as she “felt that she would blame me, not him.” This has weighed on her and has contributed to her past use of alcohol as she felt, when she drank, that “the problems were no longer there.”
In addition, Ms. Smith’s stepfather was often physically abusive to her when her mother was not at home. There were several instances when he pushed her against the wall very hard and she was knocked out briefly. She received no medical care for these injuries.
Finally, we have learned more details of Ms. Smith’s work history. Although she was able to work at the Hilton Hotel, in housekeeping, for two years, the work was intermittent, and she was frequently threatened with firing. She said, “My boss was against me. I had good ideas on how the work should be done. He wanted it his way. We frequently argued, and he would threaten me. Sometimes I was suspended for a week or two, and he would then let me back to work.” In most of her other work (the Hyatt, Marriott, and Motel 6), she had similar experiences.
In 1980, Ms. Smith was first diagnosed with a bipolar disorder when she was hospitalized at Mount Pleasant General Hospital’s psychiatry unit on an involuntary basis. The police picked her up in the street where she was yelling at people and was very agitated. Records there indicate that “she has had a two-year history of mood swings and inability to control her behavior. She has had several emergency room visits but refused voluntary admission and was deemed, at those times, as not meeting criteria for commitment. While on the unit, Ms. Smith remained manic for two weeks and only gradually responded to treatment. Discharge diagnosis was bipolar disorder, manic, with psychotic features. Medications were Zyprexa, 10 mg at bedtime, lithium, 400 mg t.i.d., and HCTZ for hypertension.”
Following this hospitalization, Ms. Smith apparently had no outpatient treatment. She remained homeless, and various emergency room records (1998–2002) indicate frequent visits there with manic/depressive symptoms and intermittent medication compliance.
In July, 2003, Ms. Smith was hospitalized again, this time at Fort Covington Psychiatric Hospital in Brynburne, New Jersey. She was again admitted involuntarily through police intervention. Records note: “Ms. Smith was extremely dirty and agitated upon admission. She spent several days in the quiet room and gradually responded to treatment. She was abusive verbally to staff and inappropriate with other patients, being intrusive and sometimes aggressive with them. On two occasions, she was put in seclusion for these behaviors. After four weeks, Ms. Smith was discharged with a diagnosis of bipolar disorder, manic, with psychotic features. Medications were Zyprexa, 10 mg at bedtime, lithium, 500 mg t.i.d., and HCTZ for hypertension. She was referred to the ACT team for follow-up and to the Safe Haven for housing.
Ms. Smith shows significant functional impairment in her activities of daily living, social functioning, and ability to persist and pace in the completion of tasks.
Regarding her activities of daily living, this report noted above that Ms. Smith’s hygiene is quite poor. She estimates that she bathes approximately once every two weeks. She is either “too busy” to bathe or feels that her depression causes her to have little interest or energy for it. She walks everywhere she needs to go, and her feet are frequently sore and swollen from all the walking. She reports having no idea as to how to use the bus or subway. In addition, she is leery of these as there are “too many people” for her to handle in public transportation. Ms. Smith has had no place to live for five years. She intermittently goes to soup kitchens to eat but sometimes feels so agitated that she simply looks for leftovers in the dumpsters behind restaurants on Main Street. She talked at length about what good food one can find in the dumpsters.
Socially, as was indicated in the employment history, Ms. Smith has a great deal of difficulty getting along with others. When she is manic, she becomes grandiose, irritable, and expects others, including employers, to do tasks “my way.” She does not understand why this causes her difficulty. On occasion, for example in the hospital, Ms. Smith becomes aggressive and suspicious of others. She has no sense of when she is being intrusive and, when manic, often acts inappropriately, e.g., singing standing in the middle of the street. When she is depressed, she isolates herself and wants no contact with anyone. When she feels this way, she sleeps on the street and eats little. She refuses even to go into the shelter at night as she “doesn’t care and has no energy.”
Regarding her ability to complete tasks, Ms. Smith, when manic, is extremely distractible. It took the writers several sessions to obtain information from Ms. Smith as she was so distractible that she was unable to stay focused on an answer to questions. She missed appointments as she was “too busy” doing “things I cannot name.” She notes that she has to write down every detail of her life or she forgets them. “I used to have a crackerjack memory,” she said.
Ms. Smith is a woman who has been homeless, psychotic, with a bipolar disorder and serious physical health problems for at least the past five years. She has had at least two known lengthy psychiatric hospitalizations. She has only recently begun taking medication and attending treatment as she is receiving the intensive services (treatment and case management) from the ACT team as well as support from the Safe Haven staff. Without these supports, Ms. Smith would likely decompensate once again and be on the street. We believe that Ms. Smith is disabled. Please contact us……if you have any questions.
Sincerely,
Jane Jones, Case manager
Sandra Smith, M.D., Psychiatrist
Disability Determination Services
P.O. Box 99
Peoria, IL 61614
Re: Jones, Jane
To Whom It May Concern:
Ms. Jane Jones was hired as an aide at our nursing home and worked here from 2000–2003 in a full–time position. During the years that Ms. Jones was here, she had to take a significant amount of medical leave. However, because she was so well liked by the staff and patients here, we granted such leave. During the last year, she was unable to do her work without someone with her virtually at all times. She would often become confused and needed help completing her assigned duties on time. Initially, other staff was more than willing to pitch in with Ms. Jones as she was very sweet, pleasant, and appreciative. However, over time, this became an impossibility for us to keep doing this amount of support, and we had to let her go. We were sorry to have to do this.
If you have further questions, please call me at 640-782-9876.
Sincerely,
Clara Barton, RN
Nursing Supervisor
Disability Determination Services
P.O. Box 55
Albany, NY 12210
Re: Sam Ellis
To Whom It May Concern:
I am the mother of Sam Ellis, who is now 27 years old. For a very long time, Sam lived with me. Last year, I couldn’t keep him here any more because he was up a lot at night, talking loudly when he was up, and kept saying very strange things to me, like he didn’t think I was his mother. I had to ask him to leave because I work and I couldn’t keep working when I wasn’t getting sleep. I felt really bad about this and worry about him all the time, but I didn’t know what else to do.
As a youngster, Sam was a quiet, obedient boy. He didn’t give me any problems when he was little. In high school, he started staying more to himself and not doing so well at school. When we would talk about it, he didn’t seem to know why. He got quieter and quieter and didn’t seem to have any friends. But he was still nice at home, so I didn’t worry too much. And he wasn’t failing at school, so that was good.
Sam then barely finished high school. After that, he really didn’t do anything. He would stay in his room all day and read or just stare at stuff. He started not taking care of himself very well and wouldn’t wash without my asking him to. He couldn’t tell me why and, when I asked, he would get really angry with me, so I stopped asking. Since my husband passed away a few years ago, it was just Sam and me at home, so I tried not to push him too much.
For a little bit of time, Sam did a few odd jobs, but he couldn’t seem to be able to keep work. He would say that the people at work were out to get him or his bosses accused him of doing wrong things. At first I believed him but then I wondered if this could happen at so many different jobs. He gave up trying to get work and then just stayed in his room. Sometimes he would say that I was trying to feed him bad food and he would refuse to eat.
I didn’t know what to do. We’ve never had problems like this before and I didn’t realize that what Sam was doing were signs of a sickness. Finally, one day, he got so upset with me I was frightened and called the police. When they got here, he was angry with them and they took him to the hospital. He was there for a couple of weeks, and I was told he had schizophrenia. He came back home and was better for a while but then fell back to his old ways.
Right now, Sam doesn’t do anything. He’s stopped taking the medicine they gave him because he said he doesn’t like it. He sometimes goes to the clinic and meets with people there but not as often as he should. He also says that he doesn’t trust those people and they’re just going to try to put him away again.
Since I had to ask him to leave, I don’t know what he does during the day. But, when he was here, he would just stay in his room, eat a little bit, and talk really loudly. When he comes here to see me now, he is dirty and smelly. I let him take a shower and try to wash the clothes he has with him if he will let me. He stops by about once or twice a week. He said that he sometimes goes in a shelter but doesn’t like the people there so he sleeps outside. He’s not eating much and looks real thin to me. I wish I could let him stay here but I just can’t. It breaks my heart to see my wonderful boy like this.
I don’t think he talks with anyone and I know he doesn’t have any friends. He said people talk about him and point at him wherever he goes. He won’t take the bus because of the people and walks here, which makes him really tired. When he comes by, I try to get him to eat something. Sometimes he will, and sometimes he won’t.
Sam has changed so much. He used to be so bright and clever. Now, he seems to get really confused when I ask him questions. He forgets to do things and can’t seem to tell me much about his life and what he does. He always seems to be distracted and thinking about something else even when I am talking to him, and he says he’s listening. I know that he hears voices and noises and that’s a big problem. I think these voices say very scary things to him.
I hope that you can help my son. I try to give him some help, but my job doesn’t pay too much, so I can’t do a lot. If you know of some place he can get help, I’d sure appreciate it. Having some income would help him get a place, and that would help him a lot, too. Thank you for reading my letter. I hope this helps. You can call me at work 999-456-2345.
Sincerely,
Sara Ellis