Please fix this assignment according to instructions and uploaded rubric. Make pt not suicidal please, I believe this Is what needs fixing.
HPI
- Add severity ratings (depression, anxiety, insomnia).
- Add aggravating factors.
- Add relieving factors.
- Add effect on daily functioning.
Family Psychiatric History
- Expand to include at least 6 family members.
- Fix the statement "brother's mother" because it is confusing.
ROS
- Psychosocial section is incorrect.
- It says the patient denies hopelessness, depressive symptoms, and poor sleep, but the entire HPI describes those symptoms.
- Change to admits hopelessness, depressive symptoms, and poor sleep.
Physical Exam
- Fix:
- "PERRLA shows vision impairment."
- "Patient does not have thyroid."
- "No discharge, gynecomastia and rashes."
- "No presence of any reflexes."
Mental Status Exam
- Improve affect description.
- Improve thought process description.
- State orientation as oriented ×4.
- Add whether thought process is logical, linear, and goal directed.
Diagnosis Section
- Strengthen justification for Adjustment Disorder.
- PHQ-9 score of 21 and active suicidal thoughts may support Major Depressive Disorder, so explain clearly why Adjustment Disorder remains the primary diagnosis.
Medication Education
For Lexapro:
- Side effects.
- Black box warning.
- Expected onset of action.
For Mirtazapine:
- Sedation.
- Weight gain.
- Dizziness precautions.
References
- Replace the 2008 insomnia guideline with a newer source.
- Add 1–2 more recent scholarly references (within 5 years).
Step 1: You will use the graduate comprehensive psychiatric/ psychotherapy evaluation template to:
- Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
- Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
oFor the Comprehensive Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).
Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See Comprehensive Evaluation Presentation 1 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
S = | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
O = | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
A = | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
P = | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up. |
Other: Incorporate current clinical guidelines, https://www.nccih.nih.gov/health/providers/clinica... or https://www.psychiatry.org/psychiatrists/practice/..., research articles, and the role of thePMHNP in your evaluation. https://www.jaacap.org/article/S0890-8567(09)62592..., https://www.jaacap.org/article/S0890-8567(09)62591.... Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare.
no plagiarism, two or more co-morbidities, psychotherapy.