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Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)

NURS6512Week5DCEAssignment2RubricDetails.html

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric

Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

	Excellent	Good	Fair	Poor
Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score.	Points: Points Range: 56 (56%) – 60 (60%) DCE score>93 Feedback:	Points: Points Range: 51 (51%) – 55 (55%) DCE Score 86-92 Feedback:	Points: Points Range: 46 (46%) – 50 (50%) DCE Score 80-85 Feedback:	Points: Points Range: 0 (0%) – 45 (45%) DCE Score <79 No DCE completed. Feedback:
Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.	Points: Points Range: 16 (16%) – 20 (20%) Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 11 (11%) – 15 (15%) Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 0 (0%) – 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. Feedback:
Objective Documentation in Provider Notes – this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).	Points: Points Range: 16 (16%) – 20 (20%) Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 11 (11%) – 15 (15%) Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 0 (0%) – 5 (5%) Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. Feedback:

Show Descriptions Show Feedback

Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score.–

Levels of Achievement: Excellent 56 (56%) – 60 (60%) DCE score>93 Good 51 (51%) – 55 (55%) DCE Score 86-92 Fair 46 (46%) – 50 (50%) DCE Score 80-85 Poor 0 (0%) – 45 (45%) DCE Score <79 No DCE completed. Feedback:

Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.–

Levels of Achievement: Excellent 16 (16%) – 20 (20%) Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Good 11 (11%) – 15 (15%) Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Fair 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Poor 0 (0%) – 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. Feedback:

Objective Documentation in Provider Notes – this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).–

Levels of Achievement: Excellent 16 (16%) – 20 (20%) Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. Good 11 (11%) – 15 (15%) Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. Fair 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. Poor 0 (0%) – 5 (5%) Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. Feedback:

Total Points: 100

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric

WK5DANNYRIVERADCEHEENTExamDocument.docx

Document: Provider Notes

Student Documentation

Subjective

Daniel who preferred to be called “Danny” Rivera is 8 years old male Spanish whose country of origin is Puerto Rico.

Chief Complaint: Danny stated, “my abuela brought me here because I’ve been feeling sick” “I have been coughing a lot, and I feel kind of tired”.

History of present condition: Cough which started about 5 days ago. Patient stated that cough is “gurgle and watery”, and the color of cough is “gross, slimy stuff”. As per patient, he takes cough medicine given by his mom in the morning, and the color of the medicine is purple. He stated that the medicine helps the cough a little and he does not remember what it is called. Patient stated, “most times I sleep for about 8 hours”, and said, “I haven’t been able to sleep much because of my cough”.

Patient reported having running nose and does not have seasonal allergy. Color of the nasal drainage is clear, watery and thin. Reported pain in the right ear and rated it 3 on a scale of 0-10. Denied pain on the left ear. Patient’s father and grandfather smoke around him.

Objective

Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.

Assessment

Cough, Fatigue, Sore throat, Rhinitis, Allergies.

Plan

Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. Educate family about administration of medication. Encourage family members not to smoke in the house. Follow up with your primary physician.

Documentation / Electronic Health Record

Document: Vitals

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Daniel who preferred to be called “Danny” Rivera is 8 years old male Spanish whose country of origin is Puerto Rico.

Medical History: No surgery, no prior hospitalization, had pneumonia last year and was treated at urgent care clinic.

Allergies: No known allergies.

Chief Complaint: Danny stated, “my abuela brought me here because I’ve been feeling sick” “I have been coughing a lot, and I feel kind of tired”. He is in 3rd grade.

History of present condition: Cough which started about 5 days ago. Patient stated that cough is “gurgle and watery”, and the color of cough is “gross, slimy stuff”. As per patient, he takes cough medicine given by his mom in the morning, and the color of the medicine is purple. He stated that the medicine helps the cough a little and he does not remember what it is called. Patient stated, “most times I sleep for about 8 hours”, and said, “I haven’t been able to sleep much because of my cough”. Patient reported having running nose and does not have seasonal allergy. Nasal Cavity color is erythema, color of the nasal drainage is clear, watery and thin. Reported pain in the right ear and rated it 3 on a scale of 0-10. Denied pain on the left ear. Patient’s father and grandfather smoke around him. Digital Clinical Experience: Focused Exam: Cough

Family History: Mother has type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, , obesity.

Father: Is a smoker, HTN, hypercholesterolemia, asthma as a child.

Maternal grand-mother: Type diabetes, HTN.

Maternal grand-father: Smoker, eczema

Paternal grand-mother: died in a car accident at age 52 years old.

Paternal grand-father: No known history.

Social history:

School attendance record: Danny has been out of school for two weeks last year due to pneumonia. He lives with his parents and grand-mother. Grand-mother takes care of him while his parents go to work. He speaks English and family use Spanish in conjunction with English.

N/A

Objective

Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L

FEV1 3.15 L (FEV1/FVC: 80.5%). Weight: 90 lbs., Ht. 4′ 2”.

Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.

N/A

Assessment

Cough, Fatigue, Sore throat, Rhinitis, Allergies.

N/A

Plan

Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. educate family about administration of medication. Encourage family member not to smoke in the house.

Follow up with your primary physician.

WEEK5ShadowHealthDCEFocusedExam-CoughDocumentation.docx

Name: Danny

Section:

Week 5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Daniel who preferred to be called “Danny” Rivera is 8 years old Spanish male whose country of origin is Puerto Rico.

Chief Complaint (CC): Cou

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Significant Family History (Include history of parents, Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. Digital Clinical Experience: Focused Exam: Cough

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Psychiatric:

Neurological:

Lymphatics:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt., temperature, and BMI and pulse oximetry

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

HEENT:

Respiratory: Always include this in your PE.

Cardiology: Always include the heart in your PE.

Lymphatics:

Psychiatric:

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. Digital Clinical Experience: Focused Exam: Cough

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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Digital Clinical Experience: Focused Exam: Cough

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Evaluation and Management (E/M) Paper

Assign DSM-5 and ICD-10 codes to services based upon the patient case scenario.

Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.

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Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

Code.docx

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. Evaluation and Management (E/M) Paper
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 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.
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. 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] Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. Evaluation and Management (E/M) Paper
Treatment Plan		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 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. Discussed how drugs/ETOH affects mental health, physical health, sleep architecture. Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. 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. 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. RTC in 30 days 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

[In 1-2 pages, address the following:

· Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.

· Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

· Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.]

Add your answers here. Delete instructions and placeholder text when you add your answers.

References

[Add APA-formatted citations for any sources you referenced]

Delete instructions and placeholder text when you add your citations.

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Clinical Case: Coaching and Teaching

Module 10 Written Assignment

develop a teaching/coaching plan on any emergency drug you pick that includes the following information. The submission is an individual assignment. You may use any books or other resources or references to complete this assignment. Use APA Editorial Format for all citations and references.

1. List the goal for this teaching/coaching plan
2. Describe three teaching resources
3. Identify the teaching strategies that can be used
4. List the specific instructions that may be needed regarding her medication and what adverse reactions to be aware of/and what to do
5. Identify two factors that may negatively influence adherence to the medication and how they can be overcome. Clinical Case: Coaching and Teaching
6. Describe how to include the family
7. Provide information on how and when she should seek support and help
8. Following your in-class activity, submit this assignment to the drop box below. Please check the Course Calendar for specific due dates. Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below: Jstudent_exampleproblem_101504

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Upper Respiratory Infection Case Study

Jackie is a 45-year-old white female with past medical history of controlled hypertension, controlled asthma, and eczema. She has a four-day history of nasal congestion, headache, sore throat, sneezing, and productive cough. She denies fever, nausea, vomiting, and myalgias. She has three children who recently went back to school following a summer vacation. No one else in her household is currently presenting with similar symptoms. She has no known drug allergies but is allergic to mums and ragweed. She calls her primary care provider’s office requesting a medication to treat her illness. She takes several medications, including the following:

• Mometasone 220 mcg—1 puff daily for asthma.

• Albuterol 90 mcg—1 to 2 puffs q4–6 hours as needed for shortness of breath.

• Lisinopril 10 mg—one tablet by mouth daily for hypertension.

• Oxymetazoline hydrochloride 0.05% nasal spray—2 sprays per nostril bid × 3 days.

Provide rationales for your answers:

1. Which of the following is the MOST appropriate drug to recommend?

a. Oxymetazoline hydrochloride 0.05% nasal spray— 2 sprays per nostril bid until symptoms resolve.

b. Naproxen 220 mg—one tablet by mouth every 12 hours as needed until symptoms resolve.

c. Dextromethorphan ER oral liquid—60 mg every 12 hours until symptoms resolve.

d. Amoxicillin–clavulanic acid 500 mg every 8 hours for seven days.

2. Which of the following nonpharmacological therapies is NOT recommended?

a. Steam inhalation

b. Increased water intake

c. Menthol lozenges

d. Saline gargle

3. Jackie is insistent on taking a complementary therapy to help treat her symptoms. What is the MOST appropriate recommendation?

a. Echinacea purpurea tincture—0.75 mL

b. Fresh garlic—3 cloves

c. Acidophilus probiotic—1 tablet daily

d. Vitamin C—1 g

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Amish Beliefs In Regards to Prenatal Care

Amish Beliefs In Regards to Prenatal Care Scenario: Mary and Elmer’s fifth child, Melvin, was born 6 weeks prematurely and is 1-month old. Sarah, age 13, Martin, age 12, and Wayne, age 8, attend the Amish elementary school located 1 mile from their home. Lucille, age 4, is staying with Mary’s sister and her family for a week because baby Melvin has been having respiratory problems, and their physician told the family he will need to be hospitalized if he does not get better within 2 days.

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Choose two or three areas of prenatal care that you would want to discuss with Mary, and then write brief notes about what you know and/or need to learn about Amish values to discuss perinatal care in a way that is culturally congruent.
Discuss three Amish values, beliefs, or practices to consider when preparing to do prenatal education classes with Amish patients.
Should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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Discussion Essay Assignment Nursing Paper

Discussion Essay Assignment Nursing Paper Discussion, Compare and contrast the growth and developmental patterns of two toddlers of different ages using Gordon’s functional health patterns. Describe and apply the components of Gordon’s functional health patterns as it applies to toddlers.

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Instructions Word limit 500 words. Support your answers with the literature and provide citations and references at least 3 less than 5 years. No plagiarism APA format. You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument. ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Discussion Essay Assignment Nursing Paper

Module 03 Assignment – Myasthenia Gravis Pamphlet

Instructions As a new nurse, you have had clients with Myasthenia Gravis (MG) and are concerned about their level of understanding of the disease process. You have taken on the task of developing a teaching pamphlet to provide clear discharge instructions including information on the disease, support resources, medication teaching, and signs and symptoms of Myasthenic Crisis. You will include the following information in the pamphlet.
1. Describe the disease process for MG.
2. List (2) local community resources available that can provide support such as:
3. Nutrition.
4. Transportation.
5. Psychosocial needs such as support groups.
6. Include medication administration instructions and the importance of timing of medication delivery.
7. Include signs of symptoms of Myanthenic Crisis and when to notify provider.

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Social Media Campaign For COVID-19

APA format

1-3 paragraphs answering each section.

Topic is Increased risk of infection with covid-19 among the population of persons aged 65 and above of Hudson County, NJ related to knowledge deficit of preventive measures such as mask wearing, social distancing and vaccination as evidenced by an overall increase in covid-19 cases.

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(B1) Health Inequity/Disparity

Explain how the health concern from your community health nursing diagnostic statement is linked to a health inequity or health disparity within the target population.

(B1a) Primary community and Prevention Resources

Discuss the primary community resources and primary prevention resources currently in place to address the health concern.

(B1b) Underlying Causes

Accurately and logically discuss the underlying causes that contribute to the selected primary health concern. (This may be similar from the information you included in section B1).

(B2) Evidence-Based Practice

Logically and appropriately include evidence-based practice article(s) relevant to the selected primary prevention field experience topic. Look for 1 or more articles that provide evidence for strategies, best practices, or guidelines that have been used to improve the problem within communities

[[This is not a section to discuss the reason for the problem in your community. Instead you should discuss the best practices (EBP) for prevention/promotion of the health concern. Discuss and in-text cite and reference scholarly journal article(s) to support the practices for the primary prevention topic.]]

(B2a) Identification of Data

In this section include relevant data relating to selected field experience topic at the local, state, or national level and discuss your findings. This should include supportive data that your prevention topic is a true problem in your community.

(C1) Social Media Campaign Objective

The description presents a measurable objective of what you hope to accomplish to improve the health concern for your population using the social media campaign. Refer to the SMART tool in the CDC intervention section: CDCynergy.

Components of the social media campaign objective should include

improving what,
for whom (target population)
by what percent
in what time frame.

(C2) Social Marketing Interventions

Provide 2 specific population focused social marketing interventions to aid in meeting your objective in section C1. Describe how each intervention would improve the health message related to the selected field experience topic.

(C3) Description of Social Media Platform

Describe applications you will use to implement your interventions (e.g. Facebook, Twitter, YouTube, Blogs, Snapchat, Instagram and others) that enable users to create and share content or to participate in social networking (electronic dissemination of ideas).

(C3a) Benefits of Social Media Platform

Discuss how each platform will support preventative healthcare in your target population for your identified health problem.

(C4) Benefit to Target Population

You will Discuss how your target population will benefit from the social media campaign. Discuss how your target population would benefit from using social media to receive the health care message.

(D) Best Practices for Social Media

Discuss the general principles for best practice in implementing all types of social media tools for healthcare marketing. Look at the key concepts from 5.1 and 5.2 in your course material and refer to the CDC social media toolkit.

(E1) Stakeholder Roles and Responsibilities

A stakeholder is someone who has an interest in the health problem and whose support is required for the social media campaign to be successful. Stakeholders have a special connection to you and your involvement in the prevention of the health problem Identify the role and responsibilities for each stakeholder

They are or could be affected by the social media campaign
They are interested in how the social media campaign will impact them
They may know what you need to know for the campaign to be successful
Points of view from community perspective
Communicates your message (e.g. Advertises your campaign)

(E2) Potential Public and Private Partnerships

Partners have a working relationship to you and collaborate in an official capacity on the social media campaign. Discuss potential public partnerships relative to implementing your campaign (Public partners are comprised of organizations that are owned and operated by the government and exist to provide services for a community (e.g. law enforcement, healthcare agencies, emergency medical service (EMS), schools). Discuss potential private partnerships relative to implementing your campaign (Private partners is usually composed of organization that are privately owned and not part of the government (e.g. businesses, independently owned institutions, grocery stores). Social Media Campaign For COVID-19

Partners:

are interested in fulfilling their role in the campaign and staying informed
they work together with you to benefit everyone involved
help to solve problems by seizing opportunity or sharing resources

(E3) Timeline

Discuss in detail the timeline with dates (week 1, week 2, etc.) for implementing the campaign.

Consider benchmarks (time points) from the planning phase to the evaluation phase.

(E4) Evaluation

Explain how you will evaluate the effectiveness of meeting your measurable objective for the social media campaign. Include a measurement tool.

(E5) Cost of Implementing the Campaign

Discuss the estimated direct/indirect costs of planning, implementing, and evaluating your campaign.

(F) Reflection on Social Media Marketing

Reflect on how the community health nurse can use social media marketing to promote healthier populations (provide one or more examples).

(F1) Reflection on Future Nursing Practice

Reflect on how you can apply a social media campaign to your future nursing practice (provide one or more examples).

Critically Analyzing and Reviewing Organizational Challenges

Make the case that one organizational challenge best meets the criteria for a doctoral capstone project.
What You Need to Know: Learn what to look for in an organizational challenge to identify opportunities for a potential doctoral capstone project.

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In determining whether the current climate of healthcare represents an opportunity for evidence-based improvement for my current organization, I would say that the pandemic has shined the light on patient safety and the Department of Defense health crisis. The current organization I am reviewing is the Defense Health Agency under which my facility the 23rd Medical Group falls under. There is sufficient evidence in literature to substantiate the DoD’s response to the current health crisis of COVID-19 given past health outbreaks. Steps of evidence-based practice (EBPs) can be reviewed from the viewpoint of conducting research and generating knowledge. One such way is the Agency for Healthcare Research and Quality (AHRQ) and patient safety models of transferring information from knowledge, social marketing, social, and organizational innovation, and behavior change. Steps of knowledge transfer through the AHRQ model represent three major stages. Knowledge creation and distillation of conducting research from various delivery systems and transportability to real-world health settings. With EBP diffusion and dissemination involves collaboration with other professional healthcare leaders in other organizations to distribute knowledge that forms the basis of action. Case in point, the sharing of information from the Centers of Disease Control to military leaders during the pandemic and getting information to audiences. The third stage involves execution and getting health organizations to adopt and use evidence-based research results. The key to EBP is getting the organization to adopt and sustain change into practice (Titler, 2008). The body of evidence that supports the challenge is based on the current pandemic. There is sufficient evidence both in military and civilian healthcare to warrant an opportunity of improvement. Based on what we have learned during the course of the last 20-months, the range of available sources of information have become more widely available. Rising disease rates, limited, funding, and the scientific basis for intervention demands the use of proven strategies to improve population health. EBP approaches and health surveillance along with policymaking are necessary tools to eradicate pandemics and change health-behaviors. The key elements of EBP in public health and military health is: Engaging the community in assessment and decision-making Using data and information systems Making decisions based on peer-reviewed evidence Applying program planning frameworks Conducting sound evaluation and disseminating what is found What has transpired and become a challenge that many organizations have faced, is that many EBP health interventions are implemented on the basis of political and media pressure (Jacobs, Jones, Gabella, Spring, & Brownson, 2012). The evidence I found comparing civilian health facilities to Air Force facilities is that more civilian data is available. While the other military services have reported numbers and responses, there is limited data specific to my site. I do not believe it is population specific but site specific because of a HIPAA related release that happened in July of 2020. This unauthorized disclosure set off a media frenzy via social media for my current facility. Therefore, sharing information is more guarded. On the other hand, with the increase of the COVID delta variant, more opportunities exist for more evidence to become present. Current metrics are that 59,337 Air Force members (military, dependents, civilian, and contractors) have been affected (Af.mil, 2021). Possible outcomes for my organization is an increase in operations that cater to the increase of manpower hours devoted to COVID screening and vaccinations.

WEEKfiveASSIGNMENT.docx

CRITICAL ANALYSIS OF ORGANIZATIONAL CHALLENGES

Introduction

When considering the improvement of an organizational challenge as the focus and topic of a doctoral capstone project, you’ll need to evaluate whether it has the necessary characteristics and elements for EBP improvement and whether it meets Capella University requirements. Critically Analyzing and Reviewing Organizational Challenges

Instructions

Critically analyze each of the identified organizational challenges you identified in Week 3 and compare them with Capella University’s criteria for an approvable doctoral capstone topic and project and with elements needed for the application of EBP improvement. Then, make a case for focusing on one challenge as the best opportunity for EBP improvement in a potential doctoral capstone project.

Requirements

The assignment requirements, outlined below, correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, note the additional requirements for document format, length, and supporting evidence. · Describe the characteristics of a professional doctorate and doctoral capstone project. . Compare professional activities and roles for individuals with a DHA or DrPH degree compared to a PhD degree. . Delineate the differences and similarities between a DHA or DrPH capstone project and a PhD dissertation. . Describe three major characteristics of a doctoral capstone project. · Critically analyze the potential of evidence-based improvement to mitigate the negative impact of each of the three identified organizational challenges. . Describe the appropriateness of applying the EBP process to mitigate the negative impact of the identified challenges. . Summarize the quality of available research evidence to support a potential project focused on mitigating the negative impact of the identified challenges. . Describe how the EBP process could facilitate improvements that mitigate the negative impact of the challenges in a short period of time. · Determine the extent to which a project focused on mitigating the negative impact of each of the three organizational challenges meets Capella University criteria for a doctoral capstone project. . Outline what a doctoral capstone project is and what it is not, according to Capella University criteria for a doctoral capstone project. . Describe how the application of existing knowledge to mitigate the negative impact of the challenges aligns with your program and specialization and contributes to your field. . Summarize Capella University criteria that would be met by a doctoral capstone project focused on mitigating the negative impact of the challenges. · Argue for the potential success and approval of a doctoral capstone project focused on the evidence-based improvement of one challenge the organization is facing. . Describe how the evidence-based improvement of one challenge meets professional doctorate, EBP, and university standards and criteria. · Write concisely and directly, using active voice. · Apply APA style and formatting to scholarly writing.

Additional Requirements

· Format: Format your paper using APA style. Use the APA Style Paper Template [DOCX]. An APA Style Paper Tutorial [DOCX] is also provided to help you in writing and formatting your paper. Be sure to include: . A title page and reference page. An abstract is not required. . A running head on all pages. . Appropriate section headings. · Length: Your paper should be 3–4 pages in length, not including the title page and reference page. · Supporting evidence: Cite at least two current and relevant peer-reviewed studies. Provide in-text citations and references in APA format.

Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive Psychiatric Evaluation and Patient Case Presentation Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

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For this Assignment, you will document information about a patient that you examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Comprehensive Psychiatric Evaluation and Patient Case Presentation

To Prepare

Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. Also, review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor.

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation?

WK5ComprehensivePsychiatricEvaluationTemplate.doc

Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template CC (chief complaint): HPI: Past Psychiatric History: · General Statement: · Caregivers (if applicable): · Hospitalizations: · Medication trials: · Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: · Current Medications: · Allergies: · Reproductive Hx: ROS: · GENERAL: · HEENT: · SKIN: · CARDIOVASCULAR: · RESPIRATORY: · GASTROINTESTINAL: · GENITOURINARY: · NEUROLOGICAL: · MUSCULOSKELETAL: · HEMATOLOGIC: · LYMPHATICS: · ENDOCRINOLOGIC: Physical exam: if applicable Diagnostic results: Assessment Mental Status Examination: Differential Diagnoses:

Reflections: References

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WK5ComprehensivePsychiatricEvaluationExemplar.doc

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example: N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment. Or P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment. Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic

Go Cha MP. General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or

Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both. Comprehensive Psychiatric Evaluation and Patient Case Presentation

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include: Where patient was born, who raised the patient Number of brothers/sisters (what order is the patient within siblings) Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children? Educational Level Hobbies: Work History: currently working/profession, disabled, unemployed, retired? Legal history: past hx, any current issues? Trauma history: Any childhood or adult history of trauma? Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination! You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History.

Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc. Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A ssessment Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone.

His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Comprehensive Psychiatric Evaluation and Patient Case Presentation

References You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

WRITINGINSTRUCTION2.docx

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW: 1). ZERO (0) PLAGIARISM 2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS) 3). PLEASE SEE THE ATTACHED RUBRIC DETAILS, Comprehensive Psychiatric Evaluation Exemplar, Comprehensive Psychiatric Evaluation Template, My Patient’s comprehensive evaluation. 4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format.

ClinicalComprehensiveEvaluation…docx

Initial Eval. 09/21/2021 CC (Chief Complaint) The patient stated, “I have lots of pressure at home and at work”.

VITAL SIGNS Height: 5’6” Weight: 272 lbs. Blood Pressure: 132/68 Temperature: 97.3 Pulse: 76 Respiratory rate: 18 O2 Saturation: 98 Pain: No pain

Diagnosis: Major Depression disorder, Insomnia

Allergies: Patient has no known drug, food, or environmental allergies

Medications Mirtazapine 15 MG Oral Tablet Take 1 tablet (15 mg) by mouth daily at bedtime.

Smoking history: Non-smoker

Gender identity: Female

Sexual Orientation: Heterosexual

Social history: Working for 17 years. Has a good relationship with peers. Past Medical History: Mood issue.

Ongoing medical problems: Problems in the house.

Family health history: Brother has mood problems. No other family member has any disorder.

Preventive care: Lives with her children.

Nutrition history: Eats poorly

Developmental history: Normal birth.

Subjective: Patient is a 41-year-old Hispanic female who has been presented for initial evaluation with consent. Weight: 272 lbs. Height: 5’6″. Patient stated, “I have pressure at home and at work”. She reported, “I don’t feel very good, I concentrate at work, but I don’t get enough sleep, and I barely eat much”. She reported that her mood goes up and down, and sometimes she cries herself to sleep. She stated that she resides in the state of Maryland with her 4 children, ages 21-, 13-, and 6-years old tweens, and raising them alone. She reported that she is married, but husband is still in their country (Mexico). She reported that she has been struggling with this issue for sometimes now. She stated that she resides in the state of Maryland.

Objective: The patient is alert and oriented 4, to person, place, time and the situation. She verbally responded to questions appropriately with intact memories. Patient reported having pressure at home and at work. She reported not sleeping good and barely eating each day. She reported that her mood is up and down, and sometimes she cries herself to sleep. The mood is euthymic, and affect is congruent with mood. Thought process is linear, goal-directed, and coherent. She denies any suicidal or homicidal ideation intent or plans at this time. Denies visual or auditory hallucinations, delusions, or paranoia. Comprehensive Psychiatric Evaluation and Patient Case Presentation Further evaluation of mental status reveals the following:

MENTAL STATUS EXAMINATION

General appearance: Appropriate, calm and cooperative with good eye contact.

Attitude: Good

Behavior: normal

Speech: Normal

Mood: Anxious

Affect: Euthymic

Thought Process: Goal directed

Thought Content: Normal

perceptions: Fair

Insight: Very good insight

judgment: Good

cognition: Good

Memory: Intact

Assessment: The patient is a 41-year-old female that presents today for an initial evaluation via telehealth, consents obtained. Patient described her chief complaint as having lots of pressure at home and at work. She reported not sleeping good at all, and barely eat each day. She stated that she cries herself to sleep most of the time. After assessing patient, provider diagnosed patient for major depressive disorder and patient stated, “you are 100% correct”. Provider prescribed Mirtazapine 15 mg for depression, also to aide in insomnia. She is educated on the importance of taking her medication as prescribed. She was encouraged using coping skills to help stabilize her mood and life style change (e.g., walking, exercise, eating right, drinking lot of water). She was also educated on the medication, its interactions, and side effects, and she verbalized understanding. Patient verbalized that she has no further concerns at this time. Provider will fill the medication at the preferred pharmacy, and she is instructed to pick it up from the pharmacy. Provider recommended therapy and patient agreed. Follow up visit in 2 weeks on 10/5/2021. Patient is encouraged to call 911 for suicidal or homicidal ideation. Plan of Care The plan is to maintain stability from depression, poor appetite and insomnia over the next 90 days Continue Mirtazapine 15 mg Educated on medication and medication interactions. Educated on the use of positive coping skills. Instructed to report any medication side effects or drug interactions. Verbalized understanding. Encourage to engage in healthy lifestyle Medication is sent to pharmacy Follow up in 2 weeks on 10/5//21 at 3:30 pm. Call 911 for suicidal or homicidal ideation.

Medications: Mirtazapine 15 MG Oral Tablet Take 1 tablet (15 mg) by mouth daily at bedtime

Comprehensive Psychiatric Evaluation Case Presentation

Digital Clinical Experience: Focused Exam: Cough

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Focused Exam: Cough Assignment:

Rubric Detail

Content

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric

Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score.–

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric

Evaluation and Management (E/M) Paper

Instructions

Identifying Information

Chief Complaint

HPI

Diagnostic Screening Results

Past Psychiatric and Substance Use Treatment

Substance Use History

Psychosocial History

Suicide / HOmicide Risk Assessment

Mental Status Examination

Clinical Impression

Diagnostic Impression

Treatment Plan

Narrative Answers

[In 1-2 pages, address the following:

· Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding.

· Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.

· Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.]

[Add APA-formatted citations for any sources you referenced]

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Introduction

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Comprehensive Psychiatric Evaluation and Patient Case Presentation

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