Week 4_assignment: assessing, diagnosing, and treating adults with

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Please review the complete instructions and use the template to complete the assignment. 

Case Study: Petunia Park

© 2020 Walden University 1

Case Study: Petunia Park

Program Transcript


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?


DR. MOORE: And what day of the week is this?

PETUNIA PARK: It’s Tuesday.


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?

Case Study: Petunia Park

© 2020 Walden University 2

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

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

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

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–


Case Study: Petunia Park

© 2020 Walden University 3

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.

DR. MOORE: OK, and what about any marijuana? When was your last use of any

PETUNIA PARK: Oh no. I tried that once and got really paranoid.

DR. MOORE: OK. What about any last use of cocaine?


DR. MOORE: Last use of any stimulants or methamphetamines?


DR. MOORE: What about any huffing or inhalants?


DR. MOORE: OK, have you used anything like Klonopin or Xanax, any of those
sedative medications?


DR. MOORE: All right, good. What about any hallucinogenics like LSD, or PCP, or

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?

Case Study: Petunia Park

© 2020 Walden University 4


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?


DR. MOORE: Good. What about any legal issues or any DUIs?


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

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?

Case Study: Petunia Park

© 2020 Walden University 5

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

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?


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?


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.

Case Study: Petunia Park

© 2020 Walden University 6

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?

Case Study: Petunia Park

© 2020 Walden University 7

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

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

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?


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?

Case Study: Petunia Park

© 2020 Walden University 8

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.


Assignment: 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.

To Prepare

· 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  138/88

Laboratory 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 – Instructions

Develop a Focused SOAP Note, (use the attached template) 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.).

· APA 7

· At least 5 references

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

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


CC (chief complaint):


Substance Current Use:

Medical History:

Current Medications:


Reproductive Hx:















Diagnostic results:


Mental Status Examination:

Diagnostic Impression:


Case Formulation and Treatment Plan: 


© 2021 Walden University

Page 1 of 3

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar


If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template

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


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 critical-thinking 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 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.)



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.


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 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.

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:
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

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.


Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).


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 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)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line
1-800-_______. 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.

© 2022 Walden University Page 1 of 3



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