HUInitialPsychiatricMentalHealthAssessment-SOAPNoteweek11forportfolio.docx

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective

Verify Patient

Name: MH

DOB: not provided

Minor: NA

Accompanied by: self

Demographic: NA

Gender Identifier Note: Male

CC: “I don’t drink when I am working and do not remember ”

.

HPI: the patient reports to the healthcare clinic reporting several symptoms. The patient’s CIWA is 10. The patient however states that she does not drink while at work. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm.

Pertinent history in record and from patient: alcohol abuse

During assessment: Patient is calm and corparative.

Patient denies hallucinating. The patient has nomal thought process. .

SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior.

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: NKDA

Describes stable course of illness.

Previous medication trials: not reported

Safety concerns:

History of Violence to Self:none reported

History of Violence t o Others: none reported

Auditory Hallucinations: not reported

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).

Substance Use: the patient reports alcohol abuse

Client does report abuse of or dependence on alcohol.

Current Medications: NKDA

(Contraceptives):

Supplements:

Past Psych Med Trials: acohol abuse

Family Medical Hx: not reported

Family Psychiatric Hx: not reported

Substance use –NKDA

Suicides-not reported

Psychiatric diagnoses/hospitalization-not reported

Developmental diagnoses

Social History:

Occupational History: currently unemployed.

Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues,no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: no fever reported.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: reports abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Objective

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: – Alcohol withdrawal ICD-10 CM-F10.230

Dx: Alcohol dependence with withdrawal, unspecified ICD-10-CM Code F10.239

Dx: Alcohol intoxication ICD-10-CM Code F10.22

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Psychiatric. NKDA

Estimated stay

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

The patient is put on Diazepam 5gm daily until she stablizes.

Alcoholism with simple withdrawal symptoms Alcohol dependence with withdrawal, simple, is a legitimate billable ICD-10 diagnostic code. It can be utilized in any HIPAA-covered transactions and can be found in the 2022 edition of the ICD-10 Clinical Modification (CM). A score for each CIWA protocol item ranges from 0 to 7, with higher values indicating more severe symptoms (Gibney, 2018). The last test question concerns orientation to time and location and is graded from 0-4. The patient's self-reported symptoms and palpable symptoms are used to calculate the CIWA score (Johansson, et al 2021).

The patient is educated on the coping skills and hoiw to take the medication as instructed.

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks

☒>50% time spent counseling/coordination of care.

Time spent in Psychotherapy 15 minutes

Visit lasted 55 minutes

____Ramona Wilkerson PHMNP student ________________________________________

NAME, TITLE

Date: 11/10/2022Time: 11:30am