NRNP 6675 Week 2 E M Patient Case Study
| WAlden University, LLC |
| Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date |
Pathways Mental Health
Psychiatric Patient Evaluation
Instructions | Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document. | |||||||||||||||||||||||||||||||||||||||||
| Identifying Information | Identification was verified by stating of their name and date of birth. Time spent for evaluation: 0900am-0957am | |||||||||||||||||||||||||||||||||||||||||
| Chief Complaint | “My other provider retired. I don’t think I’m doing so well.” | |||||||||||||||||||||||||||||||||||||||||
| HPI | 25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD. Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors. | |||||||||||||||||||||||||||||||||||||||||
| Diagnostic Screening Results | Screen of symptoms in the past 2 weeks: PHQ 9 = 0 with symptoms rated as no difficulty in functioning Interpretation of Total Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depressionGAD 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):
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 salonEducation: 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-TR and Updated ICD-10 coding]Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. | |||||||||||||||||||||||||||||||||||||||||
| Treatment Plan | 1) Medication:· Increase fluoxetine 40mg po daily for PTSD #30 1 RF· Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF Instructed to call and report any adverse reactions. Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful 2) Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing with providers. Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings. Discussed how drugs/ETOH affects mental health, physical health, sleep architecture. 3) Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment. 4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. 5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation. 6) RTC in 30 days 7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results Patient is amenable with this plan and agrees to follow treatment regimen as discussed. | |||||||||||||||||||||||||||||||||||||||||
Narrative Answers
| [In 1-2 pages, address the following:·Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and Updated 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.
E M Patient Case Study Sample
| WAlden University, LLC |
| Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date |
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, the client denied symptoms of depression, anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The 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, and has a hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of a previous rape, isolates, fearful of going outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self, or engaging in anorexic behaviors. No self-mutilation behaviors. | |||||||||||||||||||||||||||||||||||||||||
Diagnostic Screening Results | Screening of symptoms in the past two 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 being 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):
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 a Russian orphanage. She has unknown siblings. She is single; has no children. Employed at local tanning bed salonEducation: 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 a history of self-mutilation behaviors Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence. However, the risk of lethality increased under the 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 the 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 a 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 is 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 a 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; persistent 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 at 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. | |||||||||||||||||||||||||||||||||||||||||
Treatment Plan | 1) Medication: · Increase fluoxetine 40mg PO daily for PTSD #30 1 RF· Continue with atomoxetine 80mg PO daily for ADHD. #30 1 RF Instructed to call and report any adverse reactions. Future Plan: monitor for decreased re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful 2) Education: Risks and benefits of medications are discussed, including non-treatment. Potential side effects of medications discussed. Verbal informed consent was obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop the medication abruptly without discussing it 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. 3) Patient was educated about therapy and services of the MHC, including emergent care. Referral was sent via email to the therapy team for PET treatment. 4) Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to the nearest ER or call 911 if they become actively suicidal and/or homicidal. 5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand the discussion and appears to have the capacity for decision making via verbal conversation. 6) RTC in 30 days 7) Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago, and include lab results Patient is amenable with this plan and agrees to follow treatment regimen as discussed. | |||||||||||||||||||||||||||||||||||||||||
Evaluation and Management
Information Required in Documentation to Support DSM-5 and ICD-10 Coding
The documentation includes the symptoms of the condition the patient is suffering. The DSM-5 criteria have an 11 items checklist where the severity of patient symptoms is measured. The DSM includes descriptions, symptoms, and other diagnostic criteria for mental disorders (American Psychiatric Association, 2020).
It generates consistent and trustworthy diagnoses used in mental disorder research and gives a common vocabulary for physicians to talk about their patients. These documents also allow the physicians to document any behavioral changes. The important aspect is that DSM-V aids doctors in diagnosing behavioral health conditions more precisely (Stewart & DeNisco, 2019). ICD-10, on the other hand, aids billing personnel in accurately coding and billing. Because of these distinctions, an EHR system for a behavioral health provider should have both types of coding.
Missing Information and How It Can Be Helpful to Narrow down Billing and Coding Options
There should be more information about the patient’s strategies to cope with stress and triggers. This information will ensure that if the strategy needs physicians or medication, they are documented for billing (Buppert, 2021). It is also essential to measure whether the patients’ support needs are. Suppose the patient needs more than a 30-day interval between support. It can be accounted for in billing. It will ensure that the patient appointments are appropriately supported. There should also be information on where the failed medication trial occurred and the adherence plan.
Explain How To Improve Documentation To Support Coding And Billing For Maximum Reimbursement
The use of technology will allow physicians to have accurate data collection methods. It is also essential to provide training to the physicians on the key coding compliances and ensure maximization of the reimbursement issues (Pohontsch et al., 2018). There also needs to be a clinical documentation improvement to enhance adequacy and accuracy.
References
American Psychiatric Association. (2020). Updates to DSM–5 criteria, text, and ICD-10 codes. https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5
Buppert, C. (2021). Nurse practitioner\’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.
Pohontsch, N. J., Zimmermann, T., Jonas, C., Lehmann, M., Löwe, B., & Scherer, M. (2018). Coding of medically unexplained symptoms and somatoform disorders by general practitioners–an exploratory focus group study. BMC family practice, 19(1), 1-11.
Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.
Also Read: NRNP 6675 Week 5 SOAP Note Schizophrenia Spectrum Example