Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
This week, in addition to your Meditrek tracking, you will develop a comprehensive psychiatric evaluation note and video case presentation on one of the patients from a group you have interacted with in your clinical practicum.
Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
· Review this week's Learning Resources and consider the insights they provide about clinical practice guidelines.
· Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· Include at least five scholarly resources to support your assessment and diagnostic reasoning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
· Dress professionally and present yourself in a professional manner.
· Display your photo ID at the start of the video when you introduce yourself.
· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
· Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
· Objective: What observations did you make during the psychiatric assessment?
· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
· Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
· Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS
Discuss Objective data: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Discuss results of Assessment: • Results of the mental status examination • Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals
Reflections on this case: Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field.
Comprehensive Psychiatric Evaluation documentation The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Patient: ZZ 23years old, presents with Chief Complaint " I feel I have been in depression for a while and need help"
History of Present Illness Patient first time of seen a psychiatrist will be today, never seen a therapist. Depression started 2 years ago, has been progressively worse. No crying spells. Feels anxious most days of the week. Low energy. Anhedonia Patient stated he sleeps for 12hr, because he takes sleep candy, little appetite, loose interest in things he loves to do, Little concentration in online lectures, but concentrated more on video games. Has feeling of guilt about family and self. "I feel I am disappointing my family". Can feel hopeless and helpless. Denied suicidal and homicidal, No medication. Patient is a fair historian. Patient stated all this started 2 year ago but now he think he need a solution. I did not do well in school and my family is not happy. Came to US 2017 from China for school. In school for failed language course. Taking computer science classes. Has poor grades. No hx of mania or psychosis
PHQ-9 (Total: 15) Over the prior two weeks, the patient endorsed having problems with self-esteem and concentration nearly every day, interest, mood, and energy more than half the days, and sleep, appetite, and restlessness for several days. The patient denied having problems with suicidal ideation or thoughts of self harm over the past two weeks. GAD-7 (Total: 12) The patient reported having widespread worrying and fear of something awful happening nearly every day, having anxiety and trouble relaxing for more than half of the days, and having uncontrollable worrying and irritability for several days over the last two weeks. The patient denied having restlessness over the last two weeks. MoodDQ (Q1 Total: 0, Q2 Total: 0, Q3 Total: 0) The patient denied family history of bipolar disorder, being diagnosed with bipolar disorder, and having any problems with work or social function.
The patient denied experiencing: having excess energy, increased productivity, unusual self-confidence, decreased need for sleep, and racing thoughts, being unusually social and irritable, being hyper-sexual and easily distracted, participating in risky behavior, going on spending sprees, hyperactivity , and experiencing pressured speech. The patient denied experiencing several of these symptoms at once. ASRS-V1.1 (Total: 28, Part A: 3, Part B: 4) The patient endorsed very often having trouble with procrastination, very often fidgeting or squirming when seated, often having problems remembering appointments or obligations, rarely having trouble wrapping up the final details of a project and difficulty organizing the steps of a task, and rarely being hyperactive and driven in the last six months.The patient endorsed often making careless mistakes, often being restless, often having difficulty relaxing, sometimes having difficulty listening, sometimes being distracted, and rarely misplacing or losing things in the last six months. The patient denied being inattentive and unable to stay seated at meetings or gatherings, talking too much in social situations, finishing others' sentences in conversation, having difficulty waiting their turn, and interrupting others in the last six months. Stressors Areas of stress included the following: severe stress due to educational concerns, moderate stress due to family and economic concerns, and mild stress due to friends, relationship, occupational, and housing concerns. There was no stress reported in the following areas: legal and health concern s. Review of Systems An in-depth review of psychiatric system appears earlier in document. The patient reported feeling depressed, difficulty concentrating, anxiety, insomnia, and stress but no other psychiatric issues.Other than previously stated, the review of systems and organs is noncontributory for constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, musculoskeletal, allergic/immunologic, hematologic/lymphatic, general genitourinary, sex-specific genitourinary, sex-specific genitourinary, neurological, integumentary, and endocrine issues.
Substance Abuse History The patient does not have a history of substance abuse of any recreational drugs. Substance Abuse Treatment History
The patient does not have a history of any treatment for substance abuse.Consequences of Substance Abuse The patient reported having experienced no consequences as a result of their substance abuse. Inpatient Psychiatric History The patient does not have a history of inpatient psychiatric treatment.
Outpatient Psychiatric History The patient does not have a history of outpatient psychiatric treatment. Suicide/Self-Harm History The patient denied a history of suicide or self harm. Violence History Assessment The patient does not have a history of violent behavior. Past Medical History The patient denied taking any additional medications from those of their current psychiatric treatment. Psychiatric Medication History The patient does not have a recent history of taking any medications for psychiatric treatment. Patient Allergies The patient has no known medication allergies. Meds (no medications currently active) Allergies (No known allergies) Family History The patient's family does not have a history of psychiatric illness
The patient was a source of information used to complete the history documented in this note. Assessment - Sources of Risk • No evidence of acute risk of harm to self or others Suicide Risk Factors • The patient was screened for the following risk factors: prior attempt; current attempt; history of medically serious attempt; recent psychiatric hospital discharge; recent loss (particularly interpersonal or fall in social status); currently diagnosed with Major Depression; currently diminished concentration or indecision (Cognitive Impairment); current sleep problems; currently experiencing hopelessness; currently experiencing panic or significant anxiety; psychotic symptoms or underlying thought disorder or loss of rational thought (i.e., dementia); currently diagnosed with Borderline Personality Disorder; current ETOH or drug use; history of impulsivity; intense level of agitation; actively making death arrangements (updated will, suicide note, recently purchased life insurance, giving away possessions, etc.); lethal methods available or easily obtained; likely to be alone, currently socially isolated; family member committed suicide; history of childhood sexual abuse; unemployed; financial strain; and physical illness. The following risk factors for suicide/self-harm exist for this patient: • Currently diagnosed with Major Depression Suicide Protective Factors The following protective factors from suicide/self-harm exist for this patient: • Actively making future plans • Verbalizes hope for the future • Belief that suicide is immoral or will be punished (is religious, particularly Catholic) • Hopeful that current treatment direction will be effective
DSM_5 Diagnoses 296.32 Major depressive disorder, F33.1Recurrent episode, Moderate Impression MDD agrees to Wellbutrin Informed Consent The patient gave informed consent for the treatment documented in this clinical note. We discussed the limits of confidentiality. We discussed privacy policies and clinic policies, including cancellation policies. We discussed the benefits and risks of medication, including precautions and potential side effects and/or adverse reactions. Precautions and potential risks discussed include, but are not limited to: common side effects, allergic reactions, medication-induced mania, risks during lactation, risks during pregnancy, seizures, sexual dysfunction, Stevens-Johnson syndrome, suicidality, and tardive dyskinesia. Counseling and Coordination of Care Greater than 50% of session was spent on counseling and/or coordination of care. Patient/Caregiver is aware of how to contact clinical providers if concerns arise. Counseling provided to the patient/caregiver as outlined below. Addressed patient/caregiver concerns regarding current medication regimen including effectiveness, side effects, dosing range, duration, and drug interaction. Addressed patient/caregiver concerns regarding diagnosis and prognosis including accuracy of diagnosis, prognosis over time, impact of diagnosis on life functions, impact of family relationship, problematic behaviors secondary to diagnosis, and adequacy of current interventions. Psychotherapy • Cognitive Behavioral Therapy (CBT)
Plan • Continue current medication regimen • Add new medication • Continue current psychotherapy focus
Medication Wellbutrin 150mg extended release/24 1tab po every morning.