Student Name

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

WALDEN UNIVERSITY, LLC

 Pathways Mental Health
PSYCHIATRIC PATIENT EVALUATION

INSTRUCTIONS Use the following case template to complete Week 2 Assignment 1. Assign DSM-5-TR
diagnoses and ICD-10 codes to the services documented in the case scenario. You will add
your narrative answers to the assignment questions to the bottom of this template and
submit them together as one document.

IDENTIFYING Identification was verified by stating their name and date of birth.
INFORMATION
Time spent for evaluation: 1103am-1151am

CHIEF COMPLAINT “My primary doctor thinks I need more help than she can give me now.”

HPI

42 young female was evaluated for psychiatric evaluation and referred by her primary care
provider for worsening depression and panic symptoms. She is currently prescribed
escitalopram 5mg po daily for depression, alprazolam 1mg po daily for anxiety. Today, the client
reported symptoms of worsening in past month for depression with anergia, anhedonia,
motivation, reports anxiety, frequent worry, reports feeling restlessness, palpitations “feels like
everything is closing in on me, can’t focus, hard time breathing,” no reported
obsessive/compulsive behaviors. Client reported feelings like want to sleep and never wake up..
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.
Has low frustration tolerance, sleeping 10-12 hrs/24hrs, 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 week: Severity Measure for Panic Disorder = Total Score 38

PAST PSYCHIATRIC  Entered mental health system when she was age 29 after a family suicide.
AND SUBSTANCE  Previous Psychiatric Hospitalizations:
 Previous Detox/Residential treatments:

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 USE TREATMENT  Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened
nightmares), bupropion (became suicidal)
 Previous mental health diagnosis per client/medical record:

SUBSTANCE USE
HISTORY HAVE YOU USED/ABUSED ANY OF THE FOLLOWING (INCLUDE FREQUENCY/AMT/LAST USE):
Substance Y/N Frequency/Last Use
Tobacco products N
ETOH Y last drink 2 weeks ago, reports drinks
2 times weekly one drink
Cannabis N
Cocaine N
Prescription stimulants N
Methamphetamine N
Inhalants N
Sedative/sleeping pills N
Hallucinogens N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath salts, Y reports one-time ecstasy use as a
etc.) teenager

Any history of substance related:

 Blackouts: -
 Tremors: -
 DUI: -
 D/T's: -
 Seizures: -

Longest sobriety

PSYCHOSOCIAL Client was raised by single mother. She is married; has 2 children.
HISTORY Employed at local day care as administrative assistant.
Education: High School Diploma
Denied current legal issues.

SUICIDE / HOMICIDE Suicide Inquiry: Denies active suicidal ideations, intentions, or plans.
RISK ASSESSMENT

MENTAL STATUS
EXAMINATION She is a 42 yo Hispanic female who looks her stated age. She is cooperative with examiner. She is
disheveled, dressed appropriately. There is psychomotor restlessness. Her. Her mood is anxious
and mildly irritable. She denies any auditory or visual hallucinations. There is no evidence of any

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 delusional thinking. She denies any current suicidal or homicidal ideation.

CLINICAL The client is a 42 yo Hispanic female who presents with a history of treatment for depression
IMPRESSION and panic symptoms.

Moods are anxious and irritable. She has reported symptoms related to her depression and
panic. no evident mania/hypomania, no psychosis, 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.

DIAGNOSTIC [STUDENT TO PROVIDE DSM-5-TR DIAGNOSES WITH ICD-10 CODING]

IMPRESSION

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answers.

TREATMENT PLAN 1) Medication:

 Increase escitalopram 10mg po daily
 Continue with alprazolam
Instructed to call and report any adverse reactions.

2) Order labs

3) 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.

4) Time allowed for questions and answers provided. Provided supportive listening.

5) RTC in 30 days

6) Follow up with PCP for GI upset and headaches

NARRATIVE ANSWERS

[IN 1-2 PAGES, ADDRESS THE FOLLOWING:

 What reimbursement billing code would you use for this session? Provide your justification for using this
billing code.
 Explain what pertinent information is required in documentation to support your chosen DSM-5-TR
diagnoses, ICD-10 coding, and billing code.

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  Explain what pertinent documentation is missing from the case scenario and what other information
would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent
components of documentation).
 Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2
strategies for promoting legal and ethical coding and billing practices within your future clinical roles.
 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.

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 REFERENCES

ADD APA-FORMATTED CITATIONS FOR ANY SOURCES YOU REFERENCED

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