Subjective: I would start by recording what date she contacted me and the reason, which was to obtain assistance in learning about the meaning of her high cholesterol levels she received from her family doctor and additional assistance in figuring out a plan on how to address her health situation. I would make sure to mention that Mrs. M is a widow, living in the basement of her sister's home and that several of her children in the area bring her groceries due to her lack of mobility.
Once meeting with Mrs. M, I would document both the questions and any other feedback she gave during our visit. I would also mention that Mrs. M gave her consent in order to contact her family doctor to talk about her health and gain some additional insight about what her doctor wants her health and cholesterol levels to look like. I would also attach a …show more content…
M reach her goal. If Mrs. M or someone from her family requested a different approach to reach Mrs. M’s goal, then I would include those measures of interventions and their effectiveness as well. In order to gauge how effective my intervention efforts were, I would check up with Mrs. M when she called to say that she achieved her goal of getting her cholesterol levels down to a healthy measurement. I would also mention that her attitude, demeanor, and spirits seem to be lifted in a positive light. Included, would be my personal notes about her health, physical, spiritual, and mental improvements if I saw that there were any.
Revision: I would document there were no changes or deviation from the plan and that everything went accordingly in this