2023 Nursing Research and Evidence Based Practice In your practice as a nurse you may use procedures and methods that

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Nursing 2023 Nursing Research And Evidence-Based Practice

Nursing Research and Evidence Based Practice In your practice as a nurse you may use procedures and methods that 2023 Assignment

 

Nursing Research and Evidence-Based Practice

 

In your practice as a nurse, you may use procedures and methods that did not necessarily originate in evidence, but instead were derived from informal and unwritten conventions, traditions, and observations. While these techniques may have merit, practices are constantly being updated and contradicted by information from scholarly research studies and professional guidelines. This new information serves as “evidence” for revising practices to improve outcomes across health care.

 

Based on this evidence, you can formulate a question. In this Discussion, you consider the use of evidence-based practice in your own organization and formulate a question that you will need to answer for your portfolio project. This is called a PICOT question. You will also investigate strategies for overcoming barriers to implementing evidence-based practice (EBP).

 

To prepare:

 

  • Consider a recent clinical experience in which you were providing care for a patient.
  • Determine the extent to which the care that you provided was based on evidence and research findings or supported only by your organization’s standard procedures. How do you know if the tasks were based on research?
  • What questions have you thought about in a particular area of care such as a  procedure or policy? 
  • Review Chapter 2, pages 36—39 on “Asking Well worded Clinical Questions” in Polit & Beck and consult the resource from the Walden Student Center for Success: Clinical Question Anatomy & examples of PICOT questions (found in this week’s Learning Resources). Formulate your background questions and PICOT question.
  • Reflect on the barriers that might inhibit the implementation of evidence-based practice in your clinical environment.
  • Review the article “Adopting Evidence-Based Practice in Clinical Decision Making” in this week’s Learning Resources. Select one of the barriers described that is evident in your organization and formulate a plan for overcoming this barrier.

 

Post on or before Day 3:

 

  • (1)  an evaluation of the use, or lack thereof, of EBP in a recent clinical experience.
  • (2) Identify which aspects of the care delivered, if any, were based on evidence and provide your rationale.
  • (3) List your background questions and PICOT question about this nursing topic.
  • (4) Critique how the policies, procedures, and culture in your organization may hinder or support the adoption of evidence-based practices.
  • (5) Identify the barrier you selected from the article and explain how this barrier could be overcome within your organization

 

 REQUIRED RESOURCES

 

 

 

Readings

 

  • Polit, D. F., & Beck, C. T. (2012).  Nursing research: Generating and assessing evidence for nursing practice (Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
    • Chapter 1, “Introduction to Nursing Research in an Evidence-Based Practice Environment”

      This chapter provides an introduction to nursing research, its history, and the evolution of evidence-based practice. It includes an overview of credible sources of evidences and a description of the different paradigms used in nursing research.

    • Chapter 2, “Evidence-Based Nursing: Translating Research Evidence into Practice”

      The focus of this chapter includes an overview of the key aspects of evidence-based practice, a review of how to identify credible research and appraise its value, and, finally, a discussion on how to take the identified evidence and convert it into a practice.

    • Chapter 3, “Key Concepts and Steps in Qualitative and Quantitative Research”

      In this chapter, quantitative and qualitative research models are compared and the major steps in each approach are described. Information is also presented on the different sections of a research journal article and how you can identify the research model that was utilized. 

  • Adams, J. S. (2010). Utilizing evidence-based research and practice to support the infusion alliance. Journal of Infusion Nursing, 33(5), 273–277.
    Retrieved from the Walden Library databases.  

    This article examines how evidence-based research and practice supports infusion alliances. The text also specifies the increasing challenges that infusion nurses face.

  • Mallory, G. A. (2010). Professional nursing societies and evidence-based practice: Strategies to cross the quality chasm. Nursing Outlook, 58(6), 279–286.
    Retrieved from the Walden Library databases.

    This article describes strategies for reducing the gap between research knowledge and practice. The article also details how nursing societies could use these strategies to improve the quality of care.

  • Newhouse, R. P., & Spring, B. (2010). Interdisciplinary evidence-based practice: Moving from silos to synergy. Nursing Outlook, 58(6), 309–317.
    Retrieved from the Walden Library databases.

    In this article, the authors examine the state of interdisciplinary evidence-based practice (EBP). The authors detail efforts to promote interdisciplinary EBP, academic and clinical training regarding interdisciplinary EBP, and strategies that may facilitate EBP translation across disciplines.

  • Shaheen, M., Foo, S., Luyt, B., Zhang, X., Theng, Y-L., Chang, Y-K., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229–236.
    Retrieved from the Walden Library databases.

    This article reviews a study that sought to determine nurses’ awareness of, knowledge of, and attitude toward EBP. The article also describes factors likely to promote barriers to EBP adoption.

  • Shivnan, J. C. (2011). How do you support your staff? Promote EBP. Nursing Management, 42(2), 12–14.
    Retrieved from the Walden Library databases.

    This article explores the role of the nurse manager in supporting evidence-based practice. The article also explains barriers and strategies to promote EBP for a nurse manager.

  • Walden Student Center for Success. (2012). Clinical Question Anatomy. Retrieved July 9, 2014, from http://academicguides.waldenu.edu/content.php?pid=183871&sid=2950360

 

Media

 

  • Laureate Education, Inc. (Executive Producer). (2012).Timeline of nursing research. Baltimore, MD: Author.

    This multimedia piece features a timeline of major events in nursing research. The timeline highlights how historical events and seminal research have contributed to nursing practice.

 

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2023 DUE 4 8 18 7 P M EST 3 PAGES APA FORMAT NOT INCLUDING TITLE AND REFERENCE PAGE MIN 3 REFERENCES TOPIC

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Nursing 2023 3 pages not including Title and Reference page,Public Health Communication Plan on “Prescription Drug Overdose”

DUE 4 8 18 7 P M EST 3 PAGES APA FORMAT NOT INCLUDING TITLE AND REFERENCE PAGE MIN 3 REFERENCES TOPIC 2023 Assignment

DUE 4/8/18 7 P.M EST 

3 PAGES APA FORMAT NOT INCLUDING TITLE AND REFERENCE PAGE (MIN 3 REFERENCES)

TOPIC: PRESCRIPTION DRUG OVERDOSE

TARGET AUDIENCE: YOUNG ADULTS

Scholars have noted that “marketing, in general, means publicizing your name, program, and service to your target audience. Ethnic marketing employs the personal marketing strategies that best reflect the cultural values, beliefs, and norms of the ethnic audience you are targeting” (Guion, Kent, & Deihl, 2009). According to these authors, there are five keys to successful ethnic marketing:

1. Value the cultural uniqueness of your target group;

2. Value cooperation and bridge-building with community leaders and other organizations working within the community;

3. Value the cultural beliefs, symbols, and practices of your target group;

4. Value differences in languages, accents, practices, and social conduct;

5. Value word-of-mouth and interpersonal communication to spread your message.

Part III: Engage Target Audience/Communities (3 pages)

TOPIC: PRESCRIPTION DRUG OVERDOSE

TARGET MARKETING (YOUNG ADULTS)

INCLUDE SUB HEADINGS IN PAPER

· Briefly describe your target audience or community you selected for your public health campaign

· Briefly explain ways you might involve your target audience in the public health campaign

· Briefly describe two ways you will promote public relations with your target audience or community

· Briefly explain the behavior change you are hoping to facilitate among your target audience and explain the key benefits for the target audience to change their behavior

· Briefly describe potential stakeholders, community leaders, collaborative partners, or gate-keepers who may help you disseminate the message and encourage behavior change

· Briefly explain two ways stakeholders might change or impact the planning or implementation process of the public health campaign

· Briefly describe two potential barriers or challenges to accessing your target audience and explain why they are barriers or challenges

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2023 Capstone Project Topic Selection and Approval In collaboration with your approved course mentor you will

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Nursing 2023 Capstone Project Topic Selection and Approval

Capstone Project Topic Selection and Approval In collaboration with your approved course mentor you will 2023 Assignment

Capstone Project Topic Selection and Approval 

In collaboration with your approved course mentor, you will identify a specific evidence-based practice proposal topic for the capstone project. Consider the clinical environment in which you are currently working or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a quality improvement suggestion, a leadership initiative, or an educational need appropriate to your area of interest as well as your practice immersion (practicum) setting. Examples of the integration of community health, leadership, and an EBP can be found on the “Educational and Community-Based Programs” page of the Healthy People 2020 website.

Write a 500-750 word description of your proposed capstone project topic. Make sure to include the following:

  1. The problem, issue, suggestion, initiative, or educational need that will be the focus of the project
  2. The setting or context in which the problem, issue, suggestion, initiative, or educational need can be observed.
  3. A description providing a high level of detail regarding the problem, issue, suggestion, initiative, or educational need.
  4. Impact of the problem, issue, suggestion, initiative, or educational need on the work environment, the quality of care provided by staff, and patient outcomes.
  5. Significance of the problem, issue, suggestion, initiative, or educational need and its implications to nursing.
  6. A proposed solution to the identified project topic

You are required to retrieve and assess a minimum of 8 peer-reviewed articles. Plan your time accordingly to complete this assignment.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

Attempt Start Date: 02-Dec-2019 at 12:00:00 AM

Due Date: 08-Dec-2019 at 11:59:59 PM

Maximum Points: 50.0

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2023 An understanding of cells and cell behavior is a critically important component of disease diagnosis and treatment But some diseases

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Nursing 2023 Case Study Analysis

An understanding of cells and cell behavior is a critically important component of disease diagnosis and treatment But some diseases 2023 Assignment

An understanding of cells and cell behavior is a critically important component of disease diagnosis and treatment. But some diseases can be complex in nature, with a variety of factors and circumstances impacting their emergence and severity.

Effective disease analysis often requires an understanding that goes beyond isolated cell behavior. Genes, the environments in which cell processes operate, the impact of patient characteristics, and racial and ethnic variables all can have an important impact.

Photo Credit: Getty Images/Hero Images

An understanding of the signals and symptoms of alterations in cellular processes is a critical step in the diagnosis and treatment of many diseases. For APRNs, this understanding can also help educate patients and guide them through their treatment plans.

Examine a case study and analyze the symptoms presented. 

Identify cell, gene, and/or process elements that may be factored in the diagnosis.

Explain the implications to patient health.

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2023 Benchmark Teaching Diverse Learners Presentation Details For this assignment you will prepare a

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Nursing 2023 Assignment 8

Benchmark Teaching Diverse Learners Presentation Details For this assignment you will prepare a 2023 Assignment

Benchmark – Teaching Diverse Learners Presentation      

 Details: 

 For this assignment you will prepare a 10-12-slide PowerPoint presentation on teaching techniques for diverse learners.  

Presentation Criteria:  

Prepare a plan for designing and delivering instruction that addresses both the needs of the selected population as well as other diverse students.

 1.Select a population that represents a type of diversity, which may include ethnic, learning styles, age, or cognitive ability. The selected population may be nursing students, staff members, or patients. 

2.Explain how your selected population’s characteristic impacts their learning styles. 

3.Provide three teaching strategies an educator could use with that particular group of learners.

 4.Include a rationale for each strategy as to why it would be effective. 

5.Use at least three scholarly, peer-reviewed resources less than 5 years old in addition to course materials.  

Presentation Requirements:  

Online students are required to provide comprehensive speaker notes.  

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines.

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2023 Develop a three to five page paper excluding references using one of the following topics or issues Use five to

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Nursing 2023 healthcare

Develop a three to five page paper excluding references using one of the following topics or issues Use five to 2023 Assignment

 Develop a three to five-page paper excluding references using one of the following topics or issues.  Use five to ten peer reviewed or reputable references to support your paper.  Wikipedia references will not be accepted.   Here are the paper options   According to Robert Wood Foundation, Medicaid paid 62.3 percent of the total U.S. cost of long-term care in 2011, or $131.4 billion. From this statistics, it is clear Medicaid paid disproportionate share of long-term care.  What alternate sources of funding for LTC care?  You can propose new sources.  Given the sensitivity of living wills and advanced directives, should health care facilities continue to be forced to discuss them with patients? Or should patients be required (subject to exceptions) to have it prepared before ever getting hospitalized or resident in health care facilities? Baby boomers and the generations after them are more educated and technologically more savvy, and economically well off than the generations before them. Is the current LTC model sufficient to take care of them or should LTC redefine itself to accommodate the needs of them?  There is no right or wrong answer, just take a position and convincingly support your views. Is Long-term Care Insurance worth it? Given the cost of premium and sometimes limited benefits over limited time, is the assurance work it or should there be LTC care payroll deduction just like Medicare over an adult working life? Is the quality of care in LTC associated with low resources and low staffs pay? 

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2023 There are basically two assignment The first is the short answer assignment and

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Nursing 2023 Assignment 1:shotr Answer Assignment And Assignment 2: Assessing And Treating Patients With Sleep/Wake Disorders

There are basically two assignment The first is the short answer assignment and 2023 Assignment

There are basically two assignment

The first is the short answer assignment and should not exceed two pages for all the answers. there must be citations of sources for answers

The next assignment id the decision three. where you have to make the decision based on the medications and the case study posted.

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2023 Remember this paper should clearly and comprehensively identify the disease or population health problem chosen The

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Nursing 2023 Evaluation of Epidemiological Problem

Remember this paper should clearly and comprehensively identify the disease or population health problem chosen The 2023 Assignment

 Remember, this paper should clearly and comprehensively identify the disease or population health problem chosen. The problem must be an issue in your geographic area and a concern for the population you will serve upon graduation with your degree. The paper must discuss the epidemiology of the problem at three levels: local (community), state, and U.S. Remember, to include headings for each of the 7 sections below—I’ve bolded these to give you an idea of what the heading title may be. Remember to use the correct level for APA headings.
The paper should be organized into the following sections:
 

1. Introduction with a clear presentation of the problem and why it is a problem at the local, state, and national level, as well as significance and a scholarly overview of the paper. It is okay to include high-level statistics in this section to clearly identify that there is a problem in your community. Also, be sure to introduce the community/geographic region that your paper focuses on.
2. Background of the disease including definition, description, signs and symptoms, and current incidence and/or prevalence statistics current state, local, and national statistics pertaining to the disease. (Include a table of incidence or prevalence rates by your geographic county, state, and national statistics.) You will find most of this information from online sources, such as CDC, Department of Health, local health department in your chosen state, Agency for Healthcare Research and Quality’s (AHRQ), Cancer Society, and other national organizations that collect data. Please note – your table must be original and not simply a figure or table copied from another resource. Your table should be placed in an appendix which will come after your reference page.
3. A review of Current Surveillance Methods and any mandated reporting or methods for reporting the disease for providers. This section should discuss how data is collected at all three levels (local, state, national). For example, if your paper is about chlamydia, then you would discussion how patient level chlamydia data is collected and if it is mandatory to collect and report this data in your chosen geographic area, state, and in the U.S. Who collects the data? What information is collected? Don’t forget about popular studies (e.g., Framingham Heart Study), CDC, and other national surveillance systems (e.g., Youth Risk Behavior Surveillance Systems/YRBSS). Also, check with your local health department to find out if any local reporting requirements exist or if they collect the data in state or county surveys.
4. Conduct Descriptive Epidemiology analysis of the disease including who is more frequently affected and characteristics of the population that might help in creating a prevention plan. Characteristics may include, but are not limited to gender, race/ethnicity, socioeconomic status, occupation, etc. Include costs (both financial and social) associated with the disease or problem. You may find this data from recent studies, CDC, and other national/health organizations (e.g., American Heart Foundation)
5. Review how the disease is diagnosed, current national standards for Screening or Prevention, and pick one screening test and review its sensitivity, specificity, positive predictive value, cost and any current national guidelines for conducting which patients to conduct this test on. You must report the sensitivity, specificity, and PPV information for the screening test you have chosen. You may find this information in recent studies and in evidence based screening guidelines (CDC, AHRQ, American Cancer Society, etc.). Don’t forget about the U.S. Preventive Service Task Force (USPSTF).
6. Provide a brief Plan of how you will address this epidemiological disease in your practice once you are finished with school. Provide three actions you will take along with how you will measure outcomes of your actions. This section must be supported by recent, evidenced based articles (citations must be present). Each intervention must be supported by at least one recent, applicable evidenced based article per intervention. Don’t forget to discuss how you will implement your plan and how you will measure outcomes related to your plan of action(s). Remember, the three actions must be based on the needs in your chosen geographic area, as evidenced by the statistics you discuss earlier in the paper.
 

7. Conclude in a clear manner with a brief overview of key points of the entire disease. This section will summarize your paper, including major points from each of the above sections. Don’t forget the conclusion.
PREPARING THE PAPER
• Page length: 8 pages, excluding title/cover page
• APA format 6th edition
• Include at least 6 references.
• Quotations should be avoided
• Include at least one table to present information. Must be your original work!
• This paper will go through the Turnitin report for similarity percentage
 

Housekeeping:
Please and please ensure you follow every line of given instruction. Address each question accordingly.
Ensure the paper is in-line with the guidelines and grading rubric
Don’t forget to include scholarly reference(s) to support your information–not a textbook
The scholarly references must be current peer-reviewed article between year 2013 and 2018.
Ensure you include the doi or url of the reference used
Please do not use textbooks as reference.
Also note that this assignment will go through the school turnitin, hence its originality is highly essential.
Attached is the assignment-grading-rubric and guidelines  

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2023 Based on your research and understanding respond to one of the following A

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Nursing 2023 principal of nursing assessment

Based on your research and understanding respond to one of the following A 2023 Assignment

 Based on your research and understanding, respond to one of the following: 

 A young 33-year-old man is admitted to your unit with a chief complaint of “tiredness and morning headaches” even after sleeping. How you would perform a comprehensive analysis of symptoms? What are the possible causes of the symptoms? What examinations would be crucial to determine the cause of his problems? Why? 

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2023 Student Name College of Nursing PMHNP Walden University NRNP 6675 PMHNP Care Across the Lifespan II Faculty

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Nursing 2023 Assignment 1week 2

Student Name College of Nursing PMHNP Walden University NRNP 6675 PMHNP Care Across the Lifespan II Faculty 2023 Assignment

 

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

INSTRUCTIONS

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.”

HPI

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):

Substance

Y/N

Frequency/Last Use

Tobacco products

Y

½

ETOH

Y

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

Cannabis

N

Cocaine

Y

last use 2015

Prescription stimulants

Y

last use 2015

Methamphetamine

N

Inhalants

N

Sedative/sleeping pills

N

Hallucinogens

N

Street Opioids

N

Prescription opioids

N

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

Y

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

RISK FACTORS FOR SUICIDE: 

• 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

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]

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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.]

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REFERENCES

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