1. Select a client or case that you have worked within either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
2. Prepare a full mental health evaluation on your client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
a. A full psychiatric, physical, social, family, and work history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
b. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
c. A full physical assessment in addition to the mental status exam and psychiatric history
3. Develop a DSM-5 diagnostic assessment:
a. Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
4. Propose a practical, evidence-based plan of care:
a. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address those aspects of the client’s poor psychological functioning.
Requirements
1. Support your assessment, diagnosis, and treatment and management plan with appropriate literature citations.
2. The paper should be 4 pages in length, not including a title page and references.
3. Use current APA formatting and citations.
4.
Acronyms should not be used.
5. The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors and in full sentences format.
Patient Name: XXX
MRN: XXX
Date of Service: 01-27-2020
Start Time: 10:00
End Time: 10:54
Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)
Accompanied by: Brother
CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago
HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
A – with (ICD-10 code)
Differential Diagnoses:
1. choose 3 differential diagnoses
2.
3.
Definitive Diagnosis:
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
P- Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
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Formatting
Title Page
Citation
Outline
