Writing treatment notes

Criteria

Clinical Notes

Subjective

Chief Compliant : Presented to appointment by request of his mom because “my grades are getting worse.”

Patient Name: Cory

DOB : Patient reports he just turned 16 years old.

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Objective

Complete Mental Status Exam : Cory is casually dressed. Patient presents as quiet and cooperative. No agitation noted. No EPS or tardive dyskinesia noted on exam. Speech normal rate and volume. Reports mood is low due to not having the option to play sports. Reports he gets disappointed frequently. Doesn't report violent experiences before. Oriented to person, place, time and situation. Patient is objective arranged announcing that he needs to improve in school and get some work. Denies suicidal and homicidal ideation. Denies A/H and V/H.

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

Working primary diagnosis : No formal diagnoses were discussed in the video.

Differential diagnosis :

F90.9-Attention deficient hyperactivity disorder

F81.9-Developmental disorder of scholastic skills, unspecified F32.Depression

Medical diagnosis : None

Treatment options : Plan to review DSM-5 criteria for ADHD with patient to set up a formal diagnosis. . Academic testing to decide whether formative issue is available. Talk about both nonpharmacological and pharmacological designs for overseeing ADHD. Gain colateral from school to establish a plan. Think about IEP to help in individualized help.

Obstacles to treatment : Distraction and absent mindedness may imply that patient forgets to follow up with providers and attend appointments. May have disgrace encompassing psychiatric diagnosis.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

Lab work : Obtain HR, BP, and EKG. Obtain weight, height, and BMI. Assess cardiac history and family history of cardiac disease

Diagnosis: Utilize DSM-5 to confirm ADHD diagnosis. Rule out substance use disorder before prescribing a stimulant medication for ADHD to ensure safety of the patient.

Medication options : Consider Adderall to reduce symptoms of distractedness, impulsiveness, diminished school execution and hyperactivity (Stahl, Muntner and Grady, 2017). Start Adderall tablet, by mouth, 10mg and monitor for side effects and effectiveness. Prior to starting drug, the patient should be educated on the side effects as an afterthought impacts and the two guardians and child should agree to the prescription. Adderall may cause side effects of anorexia, dry mouth, weight reduction, sleep deprivation, irritability, tremors and dizziness. (Stahl, Muntner and Grady, 2017). Following one week of observing the 10mg dose it very well might be expanded by 10 mg if necessary for further effectiveness (Stahl, Muntner and Grady, 2017).

Non-pharmacological interventions : Get collateral data with school counseling services just as his educators to guarantee an individualized plan for progress is made. Assess to decide whether IEP plan is required. Moore et al., (2016) report that pulling kids out of the classroom is disruptive for social working and IEP plans should take into consideration individualized in-class interventions for the best achievement. Obtain collateral data from guardians on his earlier presentation at school and the advancement of his present manifestations.

Referrals : Referral to obtain Neuropsychological Testing to assess for learning disability or ADHD diagnosis (Ng, Heinrich and Hodges, 2019). Referral to therapist for behavioral therapy interventions and kept monitoring of symptoms (Moore et al., 2016).

Complimentary therapies: Evaluate patient's point of view on free treatments first. When to see patient next? I plan to meet this patient in about fourteen days to review neuropsychological testing results and confirm diagnosis. During that session, I plan on reviewing treatment alternatives.In the client decides to accept Adderall 10 mg, plan to meet in a week for evaluation.

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.