WK2 NRNP 6675

WALDEN UNIVERSITY, LLC

Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name Assignment Due Date

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Pathways Mental Health PSYCHIATRIC PATIENT EVALUATION

INSTRUCTIONS Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-

5 and ICD-10 codes to the services documented. You will add your narrative answers to the

assignment questions to the bottom of this template and submit altogether as one

document.

IDENTIFYING

INFORMATION

Identification was verified by stating of their name and date of birth.

Time spent for evaluation: 0900am-0957am

CHIEF

COMPLAINT

“My other provider retired. I don’t think I’m doing so well.”

HPI 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring

practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed

fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.

Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no

anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no

reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent.

There is no evidence of psychosis or delusional thinking. Client denied past episodes of

hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities,

self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily

frustrated, loses things easily, makes mistakes, hard time focusing and concentrating,

affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of

previous rape, isolates, fearful to go outside, has missed several days of work, appetite

decreased. She has somatic concerns with GI upset and headaches. Client denied any current

binging/purging behaviors, denied withholding food from self or engaging in anorexic

behaviors. No self-mutilation behaviors.

DIAGNOSTIC

SCREENING

RESULTS

Screen of symptoms in the past 2 weeks:

PHQ 9 = 0 with symptoms rated as no difficulty in functioning

Interpretation of Total Score

Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate

depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7 = 2 with symptoms rated as no difficulty in functioning

Interpreting the Total Score:

Total Score Interpretation ≥10 Possible diagnosis of GAD; confirm by further evaluation 5 Mild

Anxiety 10 Moderate anxiety 15 Severe anxiety

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MDQ screen negative

PCL-5 Screen 32

PAST PSYCHIATRIC

AND SUBSTANCE

USE TREATMENT

 Entered mental health system when she was age 19 after raped by a stranger during a house burglary.

 Previous Psychiatric Hospitalizations: denied  Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015  Previous psychotropic medication trials: sertraline (became suicidal), trazodone

(worsened nightmares), bupropion (became suicidal), Adderall (began abusing)  Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma,

PTSD, Stimulant use disorder, ADHD confirmed by school records

SUBSTANCE USE

HISTORY

Have you used/abused any of the following (include frequency/amt/last use):

Substance Y/N Frequency/Last Use

Tobacco products Y ½

ETOH Y last drink 2 weeks ago, reports drinks 1-2 times monthly one drink socially

Cannabis N

Cocaine Y last use 2015

Prescription stimulants Y last use 2015

Methamphetamine N

Inhalants N

Sedative/sleeping pills N

Hallucinogens N

Street Opioids N

Prescription opioids N

Other: specify (spice, K2, bath salts, etc.)

Y reports one-time ecstasy use in 2015

Any history of substance related:

 Blackouts: +  Tremors: -  DUI: -  D/T's: -  Seizures: -

Longest sobriety reported since 2015—stayed sober maintaining sponsor, sober friends, and meetings

PSYCHOSOCIAL

HISTORY

Client was raised by adoptive parents since age 6; from Russian orphanage. She has unknown siblings. She is single; has no children. Employed at local tanning bed salon Education: High School Diploma Denied current legal issues.

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SUICIDE /

HOMICIDE RISK

ASSESSMENT

RISK FACTORS FOR SUICIDE:

 Suicidal Ideas or plans - no

 Suicide gestures in past - no

 Psychiatric diagnosis - yes

 Physical Illness (chronic, medical) - no

 Childhood trauma - yes

 Cognition not intact - no

 Support system - yes

 Unemployment - no

 Stressful life events - yes

 Physical abuse - yes

 Sexual abuse - yes

 Family history of suicide - unknown

 Family history of mental illness - unknown

 Hopelessness - no

 Gender - female

 Marital status - single

 White race

 Access to means

 Substance abuse - in remission

PROTECTIVE FACTORS FOR SUICIDE:

 Absence of psychosis - yes

 Access to adequate health care - yes

 Advice & help seeking - yes

 Resourcefulness/Survival skills - yes

 Children - no

 Sense of responsibility - yes

 Pregnancy - no; last menses one week ago, has Norplant

 Spirituality - yes

 Life satisfaction - “fair amount”

 Positive coping skills - yes

 Positive social support - yes

 Positive therapeutic relationship - yes

 Future oriented - yes

Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors

Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence, however, risk of lethality increased under context of drugs/alcohol.

No required SAFETY PLAN related to low risk

MENTAL STATUS

EXAMINATION

She is a 25 yo Russian female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is mild psychomotor restlessness.

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Her speech is clear, coherent, normal in volume and tone, has strong cultural accent. Her thought process is ruminative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious, mildly irritable, and her affect appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.

CLINICAL

IMPRESSION

Client is a 25 yo Russian female who presents with history of treatment for PTSD, ADHD,

Stimulant use Disorder, in remission.

Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing,

avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal

symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She

denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis,

denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal

symptoms, has somatic concerns of GI upset and headaches.

At the time of disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors.

DIAGNOSTIC

IMPRESSION

[STUDENT TO PROVIDE DSM-5 AND ICD-10 CODING]

DSM-5:

 309.81 (F43.12).

 314.01 (F90.9).

ICD-10:

 F15.11.

TREATMENT PLAN 1) Medication:

 Increase fluoxetine 40mg po daily for PTSD #30 1 RF

 Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF

Instructed to call and report any adverse reactions.

Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful

2) Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop medication abruptly without discussing with providers.

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.

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Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.

3) Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800- 273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.

6) RTC in 30 days

7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results

Patient is amenable with this plan and agrees to follow treatment regimen as discussed.

NARRATIVE ANSWERS

Pertinent Information to Support DSM-5 and ICD-1o Coding

Mental health issues are difficult to diagnose as they share multiple symptoms. However, the DSM-5 and ICD-10

coding have eased these diagnoses of health issues. The evaluation and management of coding support billing in healthcare.

Patel (2016) described that timely billing and reimbursement are improved by proper coding, making it essential for any

healthcare organization. Therefore, healthcare providers must collect comprehensive information related to a health issue.

Information related to a patient, including chief complaint, social history, past medical and psychiatric history, history of

present illness, family health history, and a review of systems, is pertinent in conducting ICD-10 and DSM-5 coding

(Pohontsch et al. 2018).

Additionally, data on the physical examination and mental health status examination is essential in supporting

correct coding. Further, components of medical decision-making, including possible diagnoses, the complexity of diagnostic

tests, management and treatment options, and medical information, must be reviewed and analyzed to support the coding.

Other components of medical decision-making, including mortality, morbidity, and complications, are also important in

supporting the coding process.

Missing Documentation From the Case

In coding DSM-5 and ICD-10, identifying, analyzing, and describing all pertinent information is important in

enhancing accuracy. However, from the case scenario, there were multiple areas in which pertinent information was missing

to diagnose the mental health issues accurately. From the analysis of the case, pertinent information in the patient’s past

medical history, review of systems, family history, social history, and the findings from the patient’s physical examination

was missing. The described health issues are mental health conditions, and from the case scenario, the patient’s mental

health status examination, an important component of psychiatric examination (Amsalem et al. 2020), was not evident.

While the key symptoms of the health issue, including frustration, making mistakes, easily losing things, and difficulty

concentrating, which is currently affecting the patient’s job, were identified, key DSM-5 criteria components were not met

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as the symptoms were associated with inattentive subtype of ADHD which was not outlined. It is important to state whether

the patient’s symptoms previously met the DSM-5 diagnosis criteria for ADHD. While the symptoms of the illness have

declined with the use of the prescribed medications, the patient still exhibited impaired occupational functioning. This

implies that with more information, a healthcare provider would have not generalized ADHD but rather narrowed it down to

the specific subtype of ADHD, thereby improving the effectiveness of the treatment and management interventions.

Improving Documentation to Support Coding and Billing

Healthcare facilities always strive with revenue problems, but they can effectively maintain a strong revenue cycle

with accurate and timely data. Therefore, improving healthcare organizations’ reimbursement and coding is dependent on

the actions taken to improve clinical documentation. Payers rely on data presented in a healthcare facility’s documentation

and accurate coding to define value-based reimbursement (Merritt, 2019). Therefore, healthcare organizations have a

motivation to ensure that their clinical documentation is accurate and complete. Therefore, in their quest to improve their

documentation, these organizations must embrace different technological tools that enhance clinical documentation and

minimize the desire to use electron health record shortcuts to document. For instance, using electronic documentation

technology may minimize the desire to copy and paste previous patients’’ information for easy billing. As noted by Merritt

(2019), such shortcuts create major challenges that necessitate the continued hospitalization of patients. It is also important

for healthcare providers to use comprehensive patient assessment data to support and document complete and accurate

patient diagnoses, including the primary diagnosis, severity, comorbidities, and complications. Further, the documentation

should incorporate key procedures involved in the patient care management process.

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REFERENCES

Amsalem, D., Gothelf, D., Soul, O., Dorman, A., Ziv, A., & Gross, R. (2020). Single-day simulation-based training improves

communication and psychiatric skills of medical students. Frontiers in psychiatry, 11, 221.

https://doi.org/10.3389/fpsyt.2020.00221

Merritt, S. (2019). Successful Billing Strategies in the Hospital Industry (Doctoral dissertation, Walden University).

Patel, V. B. (2016). Evaluation and management services: documentation and coding. Techniques in Regional Anesthesia and

Pain Management, 14(4), 171-179. https://doi.org/10.1053/j.trap.2010.08.002

Pohontsch, N. J., Zimmermann, T., Jonas, C., Lehmann, M., Löwe, B., & Scherer, M. (2018). Coding of medically unexplained

symptoms and somatoform disorders by general practitioners–an exploratory focus group study. BMC family

practice, 19(1), 1-11. https://doi.org/10.1186/s12875-018-0812-8

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