WK 2 EVALUATION AND MANAGEMENT (E/M)

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 them all together as one

document.

IDENTIFYING

INFORMATION

Identification was verified by stating 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, the 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 From the patient history and psychiatric evaluation displayed above, the patient qualifies for a

total of three diagnostic impressions. The DSM-V and ICD-10 codes have been provided for

these diagnostic impressions, such as (Mandia, 2020):

1. Post-Traumatic Stress Disorder (PTSD): ICD-10 code F43.12 and DSM-V code309.81

2. Attention Deficit Hyperactive Disorder (ADHD): ICD-10 code F90.0 and DSM-V code

314.01

3. Stimulant Use Disorder: ICD-10 codes F15.20 and DSM-V code F1x.10

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/ETwOH 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 in Documenting ICD-10 and DSM-5 Coding

For the documentation of reliable ICD-10 and DSM-V coding, certain information is needed. Missing information

can lead to poor quality of care and underpayment of the offered services by the insurance scheme or payer. Some of the

crucial information contained in ICD-10 and DSM coding include patient history, physical examination, medical decision

making, patient counseling, care coordination, nature of the presenting medical condition, and time (Mandia, 2020). The

above components are broken down further into specifics. For instance, comprehensive patient history entails information

like the chief complaint, history of presenting illness, review of the system, and relevant family and social history among

others (Sarmiento & Lau, 2020). In the provided case study of a 25-year-old Russian female patient, some of this information

has been captured including the time that was spent in the provision of care services to the patient. The patient history of

presenting illness has also been illustrated comprehensively. Additional necessary information for the documentation of the

above case study includes suicide risk assessment, substance use history, mental status examination, and care plan among

others.

Missing Pertinent information in the Case Study

However, some pertinent information is missing in the provided case study, which is crucial in promoting accurate

ICD-10 and DSM-V coding and classification. For instance, the identifying information only mentions the time that was spent

with the patient leaving out the particular date that the patient was attended to (First et al., 2018). This is important in

promoting appropriate follow-up and monitoring the care outcome for the implementation of appropriate interventions.

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The identifying information of both the retiring practitioner and the attending medical practitioner is also missing. This

information is useful especially when inquiries or clarifications are needed regarding the history of drug use among other

factors.

Improving Documentation in Support of Billing and Coding for Maximum Reimbursement

To promote maximum reimbursements, the healthcare organization should adopt modern technology such as

Electronic Health Records (EHR) to promote efficient and accurate documentation of patient information (Bajowala et al.,

2020). Clinicians will find it quite easier to use the EHR system to record and update patient information. Given that

insurance schemes among other payers have a contractual obligation with the enrollees, they require consistent and reliable

documentation which can easily be attained through EHR. In case of a claim, additional information may be required

including the justification for the care services offered. As such, the adoption of good documentation practice will guarantee

patients a maximum reimbursement of the provided care services.

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REFERENCES

Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine pays: billing and coding update. Current Allergy and Asthma

Reports, 20(10), 1-9. https://doi.org/10.1007/s11882-020-00956-y

First, M. B., Rebello, T. J., Keeley, J. W., Bhargava, R., Dai, Y., Kulygina, M., ... & Reed, G. M. (2018). Do mental health

professionals use diagnostic classifications the way we think they do? A global survey. World Psychiatry, 17(2), 187-

195. DOI: 10.1002/wps.20525.

Mandia, S. (2020). Accuracy of Diagnosis Coding Based On ICD-10. Asian Pacific Journal of Health Sciences, 7(1), 43–47.

https://doi.org/10.21276/apjhs.2020.7.1.8

Sarmiento, C., & Lau, C. (2020). Diagnostic and Statistical Manual of Mental Disorders: DSM 5.‐ The Wiley Encyclopedia of

Personality and Individual Differences: Personality Processes and Individual Differences, 125-129.

https://doi.org/10.1002/9781119547174.ch198

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