Description
ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Consider patient diagnostics missing from the video: Provider Review outside of interview:Temp 98.2 Pulse 90 Respiration 18 B/P 138/88Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
THE ASSIGNMENT
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Unformatted Attachment Preview
[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re here
for a mental health assessment today? PETUNIA PARK: That’s right. DR. MOORE: OK. So to make sure I have the right
patient and the right chart, can you tell me your name
and your date of birth? PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995. DR. MOORE: And can you tell
me what today’s date is? PETUNIA PARK: So
it’s December 1. DR. MOORE: Do you know the year? PETUNIA PARK: 2020. DR. MOORE: And what day
of the week is this? PETUNIA PARK: It’s Tuesday. [CHUCKLING] DR. MOORE: And do you
know where we are today? PETUNIA PARK: Yes I am here
in the beautiful, sunny office at the clinic. DR. MOORE: OK, great. Thank you. So can you tell me a little bit
about why you’re here today? What brings you here today? PETUNIA PARK: Yes. So I have a history of taking
medications and then stopping them. I don’t think I need them. I really feel like the
medication squashes who I am. DR. MOORE: OK, OK. So I’m going to be able
to help you with that. But to begin, I’m going
to ask you some questions about your family. I’m going to ask you some
history-type questions. I’m going to ask
you some symptoms that you might be having. And all of these
questions are going to help me work with you
on a treatment plan, OK? So I would like to
begin with, when was the first time that you
ever had any mental health or substance use
treatment in your life? PETUNIA PARK: OK. Well, when I was a teenager,
my mom put me in the hospital after I went four or five
days without sleeping. I think I may have been
hearing things at that time. [CHUCKLES] I think they
started me on some medication, but I’m not sure. DR. MOORE: Oh, OK so
you were hospitalized. How many times have you been
hospitalized for mental health? PETUNIA PARK: Oh, I’ve been
hospitalized about four times. The last time was
this past spring. No detox or residential
rehabs, though. DR. MOORE: OK, good. Were any of these
hospitalizations due to any suicide gestures? PETUNIA PARK: One was in 2017. I overdosed on
Benadryl, but I’ve not had those thoughts since then. DR. MOORE: Well, I’m very glad
to hear that you’ve not had any of those thoughts since then. And I’m glad that you turned
out OK from that overdose. I’m glad that you’re here today. Can you tell me a
little bit about what you’ve been diagnosed with
during your past treatments? PETUNIA PARK: Well,
I think depression, and anxiety, had some
even say maybe bipolar. DR. MOORE: OK, and
what medications have you been tried on
before for those illnesses? And if you can remember,
what was your reactions to those medications? PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that
made me feel really high. [CHUCKLES] I couldn’t sleep. My mind was racing, and
then I took risperidone. That made me gain
a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and that
seems to slow me down some. I really can’t
remember the others. I think the one I just
stopped taking was helping. It started with an L, I think. I don’t really
remember the name, but it squashed
me in creativity. DR. MOORE: OK, well,
we’re going to try to help you find some
medication that doesn’t make you feel squashed or have any of
those negative side effects today. But in order to do that, I
need some more information. And the next questions I’m going
to ask you are about substances you may have used. And I want you to know that you
don’t get in trouble in here if you’ve used some
of these substances. It really just helps
me to make sure that what’s in your
system that could be impacting your neurochemistry. And when we do talk
about medications, so I don’t give you something
that would negatively interact with something
you may be using, OK? So do you– PETUNIA PARK: OK. DR. MOORE: –use any nicotine? PETUNIA PARK: Yes. I smoke about a pack
a day, and I’m not going to quit for you, either. [CHUCKLES] Oh. DR. MOORE: That’s OK, that’s OK. And what about alcohol? When was your last
drink of alcohol? PETUNIA PARK: When I
was 19 because alcohol and me do not work
well together. [CHUCKLES] DR. MOORE: OK, and what
about any marijuana? When was your last
use of any marijuana? PETUNIA PARK: Oh no. I tried that once and
got really paranoid. DR. MOORE: OK. What about any last
use of cocaine? PETUNIA PARK: Never. DR. MOORE: Last use of any
stimulants or methamphetamines? PETUNIA PARK: Never. DR. MOORE: What about
any huffing or inhalants? PETUNIA PARK: Never. DR. MOORE: OK, have
you used anything like Klonopin or Xanax, any
of those sedative medications? PETUNIA PARK: Never. DR. MOORE: All right, good. What about any hallucinogenics
like LSD, or PCP, or mushrooms? PETUNIA PARK: No, never. DR. MOORE: Wonderful. OK, what about any use of pain
pills or opiate medications? Anything prescribed
or anything you’ve obtained from the street? PETUNIA PARK: No, never. DR. MOORE: Good. And anything synthetic like
Spice, or ecstasy, Bath Salts, Mollies, anything like that? PETUNIA PARK: Never. DR. MOORE: Oh, wonderful. Well, I’m glad to hear that. You know those things
aren’t good for your brain. So I encourage you to continue
to stay away from those things. Have you ever had any
blackouts or seizures from drugs or alcohol? Or seen things that you
weren’t sure were there? PETUNIA PARK: Never. DR. MOORE: Good. What about any legal
issues or any DUIs? PETUNIA PARK: Never. DR. MOORE: OK. Good, good. All right, so I’m just
going to ask a little bit about your family right now. Any blood relatives have any
mental health or substance abuse issues? PETUNIA PARK: Yeah, well,
well, why would you ask that? It’s not your business. DR. MOORE: Right. I could see where you
might find that wouldn’t be any my business. But really, sometimes these
issues can be genetic. They’re alarm behaviors. So my understanding
of your family helps me to understand you. PETUNIA PARK: Huh. Well, my mother
was seen as crazy. I think they said she
had bipolar or something. And my father went
to prison for drugs. And well, we haven’t heard,
or seen, or heard from him in 8 or 10 years. My brother, while I think
he’s a little schizo, but he hasn’t ever
went to the doctor. Nobody else with anything. DR. MOORE: OK. So that sounds like
it must be tough growing up not
seeing your father and having some of those
issues in your family. But any family, blood
relatives commit suicide? PETUNIA PARK: Well, my mom
tried, but nobody really did it, you know? DR. MOORE: OK. Have you ever done anything
like that, or anything like cut on yourself, burn yourself? PETUNIA PARK: I already told
you, I tried to kill myself. Why ask me that again? No, I’m not going to kill
myself or anyone else, and I don’t cut myself. DR. MOORE: OK. Well, I’m glad to hear that. And I want you to know
that I am here for you, and we most certainly
will make sure you have a crisis like number
at the end of this session if you do have those
thoughts in the future. So I’m glad to
hear that you don’t have those thoughts today. OK. What type of medical
issues do you have? PETUNIA PARK: Oh, hoo. Let’s see. I have a thyroid issue that
I take some medicine for, that hypothyroidism. And I take a birth control
pill for polycystic ovaries. DR. MOORE: OK, when
was your last menses? PETUNIA PARK: Oh, well I have
a regular one each month. So let’s see. It was last month sometime. DR. MOORE: OK, so any
chance that you’re pregnant? PETUNIA PARK:
[LAUGHS] Lordy, no. I may have a lot of sex
around, but I’m safe. DR. MOORE: Hm. You “have a lot of sex around.” Can you maybe tell
me what that means? PETUNIA PARK: Well, it’s
exciting and thrilling to find new people to explore sex with. It helps me keep my
moods high, high, high. [CHUCKLES] DR. MOORE: OK, so that makes
you feel really high and kind of what, OK? PETUNIA PARK: Oh yeah. DR. MOORE: So who raised you? PETUNIA PARK: My mom and
my older brother, mainly. DR. MOORE: And who
do you live with now? PETUNIA PARK: Well, I
live with my boyfriend. And sometimes, stay with my
mom when he gets mad at me for sleeping around some. DR. MOORE: So that’s
created some issues in your relationship, I see. OK. Are you single, married,
widowed, or divorced? PETUNIA PARK: I’ve
never been married. DR. MOORE: OK. Do you have any children? PETUNIA PARK: No. DR. MOORE: All right. Are you working? PETUNIA PARK: Yes, I work part
time at my aunt’s bookstore. She’s more tolerant of
the days I don’t come in from feeling too depressed. DR. MOORE: OK, so I hear some,
maybe, feelings of depressed. OK. What is your level of education? PETUNIA PARK: Oh,
I’m in vo-tech school right now for cosmetology. I’m going to do makeup
for movie stars. [CHUCKLES] DR. MOORE: Oh, that
sounds really wonderful. OK, so but what about now? What do you do for fun now? PETUNIA PARK: Well, I am
writing my life story, and it’s going to be published. I also paint like Picasso. I’m going to sell those
paintings to movie stars, too. DR. MOORE: Well,
that’s wonderful. Maybe someday you can show
me your paintings as well. OK, have you ever been arrested
or convicted for anything? PETUNIA PARK: No. The police did pick me up and
take me to the hospital once. I didn’t have much
sleep that week. And they said I was dancing
around in my nightgown in a field with my guitar. I really don’t remember
much of that, though. I think maybe my mom made
up that story against me because she wanted me to go
back to my boyfriend’s house. DR. MOORE: OK, so that was
one of your hospitalizations that we talked about earlier. OK, what about any history of
trauma with childhood or adult? Any kind of physical,
sexual, emotional abuse? PETUNIA PARK: Well, my
dad was pretty hard on us when he was around. But he didn’t really
touch us or anything. More just yelled at us a lot. DR. MOORE: OK. All right, so I’ve
gathered some history here. Now, I want to get
into more of some of the symptoms that brought
you in to see me today. So you mentioned before that
sometimes your depression keeps you from working
at your aunt’s bookstore. Can you tell me
a little bit more about what that
looks like for you? PETUNIA PARK: Well, about
four or five times a year, I have these times when I just
don’t want to get out of bed. I have no energy, no
motivation to do anything. I just can’t feel any
interest in my creativity. I feel like I’m not worth
anything because I feel that creativity slipping away. So this is usually
happening after I’ve been up for five
days working hard on my works with my writing,
painting, and music. Everyone says I’m
depressed, but I’m not sure. It could be that I’m just
exhausted from working so hard. DR. MOORE: OK, so I hear you
talking about these creativity episodes right before you crash. Per se, this depression. Tell me a little bit more
about those episodes. What do those look like for you? PETUNIA PARK: Oh,
I love those times. Those are the reasons
I don’t always take my medication because
I feel like I’m squashed. I have lots of energy
to do a lot of things. I can go four or five days
with very little sleep. I get lots of things
done, but my friends tell me I talk too much
and appear scattered. [SIGHS] They’re just jealous
of all the accomplishments I’m getting done. These are the times I
look to explore my mind and body with feeling good
through sex with other people. DR. MOORE: OK, how long do
those episodes last typically when you have them? PETUNIA PARK: About a week. DR. MOORE: About a week. OK. So I want to ask a little bit
more about some other symptoms that maybe we
haven’t talked about. Do you feel like you worry
a lot or have any kind of anxiety and panic symptoms? PETUNIA PARK: No, no no. I’m not a worry. DR. MOORE: OK, do
you do anything that you feel like you have to
do repetitively over and over? And if you can’t do them, you
feel like the end of the world is coming? Something like maybe
count on threes or wash your hands 20 times? Anything like that? PETUNIA PARK: [LAUGHS] No, no. I don’t have OCD, if
that’s what you’re asking. DR. MOORE: OK, what about
hearing or seeing things you’re not sure
others see or hear? Anything like that? PETUNIA PARK: Not right now. It’s been a couple of
months since that happened. Sometimes when I’m
not sleeping good, I hear voices telling me how
great and wonderfully talented I am. DR. MOORE: OK. So, but no voices right now? PETUNIA PARK: No. DR. MOORE: OK, good. What about your appetite? How’s your appetite? PETUNIA PARK: Well, when
I’m really creative, I’m too busy to eat. And when I’m
crashing and resting, I eat everything in sight. DR. MOORE: OK, so
what about your sleep? On average, how much time
do you think you sleep in a whole 24-hour period? And do you have any bad dreams? PETUNIA PARK: No bad dreams. Most of the time, I get
about five or six hours. When I’m creative,
I’m lucky to get three hours and a whole week. Ugh. And when I’m crashed, I sleep
about 12 or 16 hours a day. DR. MOORE: OK, wonderful. So this is great. I have a lot of
information from you that I think we will be able to
come up with a treatment plan and maybe find some
medication that’s going to help you feel better
without you feeling so squashed and having negative
side effects, but really help you be able
to function through the day. [MUSIC PLAYING]Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
•
•
•
Current Medications:
Allergies:
Reproductive Hx:
ROS:
•
•
•
•
•
•
•
•
•
•
•
•
GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
References
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NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ
CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused
SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to
review the rubric in detail in order not to lose points unnecessarily because you missed
something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
•
•
•
•
•
•
Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and
medical history
• Allergies
• ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
•
Physical exam documentation of systems pertinent to the chief complaint,
HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed
to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
•
•
•
Results of the mental status examination, presented in paragraph form.
At least three differentials with supporting evidence. List them from top priority
to least priority. Compare the DSM-5-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TR criteria rules out the
differential diagnosis to find an accurate diagnosis. Explain the criticalthinking process that led you to the primary diagnosis you selected. Include
pertinent positives and pertinent negatives for the specific patient case.
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related to legal/ethical
considerations (demonstrate critical thinking beyond confidentiality and consent
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Exemplar
for treatment!), social determinates of health, 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.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note.
You will practice writing this type of note in this course. You will be focusing more on the
symptoms from your differential diagnosis from the comprehensive psychiatric
evaluation narrowing to your diagnostic impression. You will write up what symptoms
are present and what symptoms are not present from illnesses to demonstrate you have
indeed assessed for illnesses which could be impacting your patient. For example,
anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
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 medication management follow up for
anxiety. He was initiated sertraline last appt which he finds was effective for two weeks
then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous
psychiatric evaluation for concentration difficulty. She is not currently prescribed
psychotropic medications as we deferred until further testing and screening was
conducted.
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. First what is bringing the patient to your
follow up evaluation? Document symptom onset, duration, frequency, severity, and
impact. What has worsened or improved since last appointment? What stressors are
they facing? Your description here will guide your differential diagnoses into your
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Exemplar
diagnostic impression. 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.
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.
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
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Exemplar
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.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to
develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
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.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your
diagnostic impression. You must explain how and why (your rationale) you ruled out
any of your differential diagnoses. You must explain how and why (your rationale) you
concluded to your diagnostic impression. You will use supporting evidence from the
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literature to support your rationale. 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!), social determinates of health, 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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions including psychotherapy and/or
psychopharmacology, education, disposition of the patient, and any planned follow-up
visits. Each diagnosis or condition documented in the assessment should be addressed
in the plan. The details of the plan should follow an orderly manner. *See an example
below. You will modify to your practice so there may be information
excluded/included. If you are completing this for a practicum, what does your
preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side
effects of medications discussed (be detailed in what side effects discussed). Informed
client not to stop medication abruptly without discussing with providers. Instructed to call
and report any adverse reactions. Discussed risk of medication with pregnancy/fetus,
encouraged birth control, discussed if does become pregnant to inform provider as soon
as possible. Discussed how some medications might decreased birth control pill, would
need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs.
Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol
affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or
referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if
not provided by you)
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Exemplar
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1800-_______. Client instructed to go to nearest ER or call 911 if they become actively
suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed
PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client
appeared to understand discussion. Client is amenable with this plan and agrees to
follow treatment regimen as discussed. (this relates to informed consent; you will need
to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for
ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve
functioning, and prevent the need for a higher level of care.
References (move to begin on next page)
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.
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