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



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.”



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     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 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):





Frequency/Last Use


Tobacco       products






last       drink 2 weeks ago, reports drinks 1-2 times monthly one drink       socially 







last use       2015


Prescription       stimulants


last use       2015








Sedative/sleeping       pills






Street       Opioids



Prescription       opioids



Other:       specify (spice, K2, bath salts, etc.)


reports       one-time ecstasy use in 2015

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 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


· 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 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 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 and 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.



[Add APA-formatted citations for any sources you referenced]

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