Assignment 1: Evaluation and Management (E/M)

Kofo Calloway

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Professor Daphne Essex

12 June, 2022

Instructions

Identifying Information

Time spent for evaluation: 0900am-0957am

Chief Complaint

HPI

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

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

·       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

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

·       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

Clinical Impression

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

DSM-V CODE: Post traumatic stress disorder (PTSD)

ICD-10 CODE: F43.1

Treatment Plan

·       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.

The relevant information needed in documentation to support DSM V coding includes diagnostic clinical features, associated symptoms supporting diagnosis, risk factors, diagnostic measures, prognostic factors, and functional consequences (First et al., 2021). In addition, information on gender and culture-associated diagnostic issues, differential diagnoses, and recording procedures is needed in the documentation. Pertinent information needed in ICD-10 coding includes the causes, clinical manifestations, severity of symptoms, and the type of illness or injury (Monestime et al., 2019).

The case scenario lacks important documentation like the severity of clinical symptoms, primary diagnosis, the patient’s comorbidities, and the differential diagnoses with their DSM V and ICD-10 codes. The coding and billing options can be narrowed down by including information such as the clinician’s details and the patient’s demographic information. The clinician’s details include the name, signature, location, and the National Provider Identifier (NPI). Besides, the patient information should include the name, age/date of birth, and insurance information (Seligson et al., 2021). Furthermore, coding and billing can be narrowed by including details about the clinical visit, such as the date and time of the visit, procedure codes, code modifiers, the number of items used, and authorization data.

Healthcare organizations can improve the quality of clinical documentation by leveraging technology and educating healthcare providers in order to improve coding compliance and maximize reimbursement. Healthcare technology can potentially restructure and optimize coding, claims management, and reimbursement. Technology can make coding and clinical documentation easier (Jaqua et al., 2020). For instance, Computer-assisted coding (CAC) solutions extract data from patient records and transfer it to the coder, allowing the coder to focus on creating a story. In addition, providing staff education is crucial in improving documentation among healthcare providers (Seligson et al., 2021). The staff should be trained on using technology in the documentation and why they need to document in a particular way to support coding and billing processes and ensure maximum reimbursement.

Instructions

Identifying Information

Time spent for evaluation: 0900am-0957am

Chief Complaint

HPI

Today, the client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking.  Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.

Diagnostic Screening Results

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

·         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

Employed at local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / HOmicide Risk Assessment

·         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

Clinical Impression

Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, has somatic concerns of GI upset and headaches.

At the time of disposition, the client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low risk for self-harm based on her current clinical presentation and her risk and protective factors.

Diagnostic Impression

From the patient history and psychiatric evaluation displayed above, the patient qualifies for a total of three diagnostic impressions. The DSM-V and ICD-10 codes have been provided  for these diagnostic impressions, such as (Mandia, 2020):

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

2.       Attention Deficit Hyperactive Disorder (ADHD): ICD-10 code F90.0 and DSM-V code 314.01

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

Treatment Plan

·         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/ETwOH affects mental health, physical health, sleep architecture.

3)       Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.

4)       Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

5)       Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation.

6)       RTC in 30 days

7)       Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab results

Patient is amenable with this plan and agrees to follow treatment regimen as discussed.