NUR 601 Module 2 Discussion CASE 2
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– ## WEEK2ASSIGNMENT1NONPRACNRNP6675Week2EMPatientCaseStudyrev.4.2024.docx **## WEEK2ASSIGNMENT1NONPRACNRNP6675Week2EMPatientCaseStudyrev.4.2024.docx** Pathways Mental Health Psychiatric Patient Evaluation | | | | | — | — | — |…
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**## WEEK2ASSIGNMENT1NONPRACNRNP6675Week2EMPatientCaseStudyrev.4.2024.docx**
Pathways Mental Health
Psychiatric Patient Evaluation
| | | |
| — | — | — |
| ## **Instructions** | | **Use the following case template to complete Week 2 Assignment 1. Assign**<br>**_DSM-5-TR_ diagnoses**<br>**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 Information | | Identification was verified by stating their name and date of birth.<br>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. <br>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: <br>Severity Measure for Panic Disorder = Total Score 38 |
| ## Past Psychiatric and Substance Use Treatment | | Entered mental health system when she was age 29 after a family suicide.<br>Previous Psychiatric Hospitalizations: <br>Previous Detox/Residential treatments: <br>Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal)<br>Previous mental health diagnosis per client/medical record: |
| ## Psychosocial History | | Client was raised by single mother. She is married; has 2 children. <br>Employed at local day care as administrative assistant.<br>Education: High School Diploma<br>Denied current legal issues. |
| ## Suicide / Homicide Risk Assessment | | Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. |
| ## 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 delusional thinking. She denies any current suicidal or homicidal ideation. |
| ## Clinical Impression | | The client is a 42 yo Hispanic female who presents with a history of treatment for depression and panic symptoms.<br>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. <br>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 Impression | | [Student to provide DSM-5-TR diagnoses with ICD-10 coding]<br>Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. |
| ## Treatment Plan | | Medication: <br>Increase escitalopram 10mg po daily <br>Continue with alprazolam<br>Instructed to call and report any adverse reactions. <br>Order labs<br>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.<br>Time allowed for questions and answers provided. Provided supportive listening.<br>RTC in 30 days <br>Follow up with PCP for GI upset and headaches |
| |
## Narrative Answers
| | |
| — | — |
| | ### [In 1-2 pages, address the following:<br>### · What reimbursement billing code would you use for this session? Provide your justification for using this billing code.<br>### · Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.<br>### · 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).<br>### · 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.<br>### · Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.<br>Add your answers here. Delete instructions and placeholder text when you add your answers. |
References
### Add APA-formatted citations for any sources you referenced
Delete instructions and placeholder text when you add your citations.
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| Page | 2 | Walden University, LLC rev 4.2024 |
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**## WEEK2ASSIGNMENT1NONPRACNRNP6675Week2EMPatientCaseStudyrev.4.2024.docx**
Pathways Mental Health
Psychiatric Patient Evaluation
| | | |
| — | — | — |
| ## **Instructions** | | **Use the following case template to complete Week 2 Assignment 1. Assign**<br>**_DSM-5-TR_ diagnoses**<br>**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 Information | | Identification was verified by stating their name and date of birth.<br>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. <br>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: <br>Severity Measure for Panic Disorder = Total Score 38 |
| ## Past Psychiatric and Substance Use Treatment | | Entered mental health system when she was age 29 after a family suicide.<br>Previous Psychiatric Hospitalizations: <br>Previous Detox/Residential treatments: <br>Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal)<br>Previous mental health diagnosis per client/medical record: |
| ## Psychosocial History | | Client was raised by single mother. She is married; has 2 children. <br>Employed at local day care as administrative assistant.<br>Education: High School Diploma<br>Denied current legal issues. |
| ## Suicide / Homicide Risk Assessment | | Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. |
| ## 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 delusional thinking. She denies any current suicidal or homicidal ideation. |
| ## Clinical Impression | | The client is a 42 yo Hispanic female who presents with a history of treatment for depression and panic symptoms.<br>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. <br>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 Impression | | [Student to provide DSM-5-TR diagnoses with ICD-10 coding]<br>Double click inside this text box to add/edit text. Delete placeholder text when you add your answers. |
| ## Treatment Plan | | Medication: <br>Increase escitalopram 10mg po daily <br>Continue with alprazolam<br>Instructed to call and report any adverse reactions. <br>Order labs<br>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.<br>Time allowed for questions and answers provided. Provided supportive listening.<br>RTC in 30 days <br>Follow up with PCP for GI upset and headaches |
| |
## Narrative Answers
| | |
| — | — |
| | ### [In 1-2 pages, address the following:<br>### · What reimbursement billing code would you use for this session? Provide your justification for using this billing code.<br>### · Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.<br>### · 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).<br>### · 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.<br>### · Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.<br>Add your answers here. Delete instructions and placeholder text when you add your answers. |
References
### Add APA-formatted citations for any sources you referenced
Delete instructions and placeholder text when you add your citations.
| | |
| — | — |
| Page | 2 | Walden University, LLC rev 4.2024 |
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– ## WEEK2ASSIGNMENT2_NONPRAC6675.docx **## WEEK2ASSIGNMENT2_NONPRAC6675.docx** PP PPPP **PREPARE:** Reflect on the study plan you created in NRNP 6665. Did you accomplish your SMART goals? What areas of focus still present opportunities for growth? The Assignment **ASSIGNMENT**: Revise your study…
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**## WEEK2ASSIGNMENT2_NONPRAC6675.docx**
PP
PPPP
**PREPARE:** Reflect on the study plan you created in NRNP 6665. Did you accomplish your SMART goals? What areas of focus still present opportunities for growth?
The Assignment
**ASSIGNMENT**: Revise your study plan summarizing your current strengths and opportunities for improvement.
· Develop 3–4 new SMART goals for this quarter and the tasks you need to complete to accomplish each goal. Include a timetable for accomplishing them and a description of how you will measure your progress.
· Describe resources you would use to accomplish your goals and tasks, such as ways to participate in a study group or review course, mnemonics and other mental strategies, and print or online resources you could use to study. You will submit 2 documents: the previous NRNP 6665 study plan and your NRNP 6675 revised study plan.
By Day 7 of Week 2
**Submit** your previous NRNP 6665 study plan and revised NRNP 6675 study plan.
submission information
**## WEEK2ASSIGNMENT2_NONPRAC6675.docx**
PP
PPPP
**PREPARE:** Reflect on the study plan you created in NRNP 6665. Did you accomplish your SMART goals? What areas of focus still present opportunities for growth?
The Assignment
**ASSIGNMENT**: Revise your study plan summarizing your current strengths and opportunities for improvement.
· Develop 3–4 new SMART goals for this quarter and the tasks you need to complete to accomplish each goal. Include a timetable for accomplishing them and a description of how you will measure your progress.
· Describe resources you would use to accomplish your goals and tasks, such as ways to participate in a study group or review course, mnemonics and other mental strategies, and print or online resources you could use to study. You will submit 2 documents: the previous NRNP 6665 study plan and your NRNP 6675 revised study plan.
By Day 7 of Week 2
**Submit** your previous NRNP 6665 study plan and revised NRNP 6675 study plan.
submission information
PLEASE COMPLETE IN DETAIL – ## WK3ASSIGNMENTHP-2141.docx **## WK3ASSIGNMENTHP-2141.docx** **WK3 ASSIGNMENT HP-214** **Tracking Finances** This week we looked at Revenue Cycle Management with an emphasis on tracking patient services, charges, payments, and adjustments. Your homework assignment is to …
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– ## WK3ASSIGNMENTHP-2141.docx
**## WK3ASSIGNMENTHP-2141.docx**
**WK3 ASSIGNMENT HP-214**
**Tracking Finances**
This week we looked at Revenue Cycle Management with an emphasis on tracking patient services, charges, payments, and adjustments. Your homework assignment is to complete three of the forms that you may use as a billing specialist.
There are a total of 87 entries for you to complete. The assignment score will reflect the number of correct entries made.
Use the assignment document to complete
## Tracking Finances – W3A INFORMATION
This week we looked at Revenue Cycle Management with an emphasis on tracking patient services, charges, payments, and adjustments. Your homework assignment is to complete three of the forms that you may use as a billing specialist.
There are a total of 87 entries for you to complete. The assignment score will reflect the number of correct entries made.
**Include the following aspects in the assignment:**
Download and open:
[Week 3 Homework](https://content.grantham.edu/academics/GU_AH214b/W3Homework.docx). Follow the instructions to complete the work and submit the file as your homework assignment.
## Part 1: Patient Ledger
Complete the patient ledger for the Ben Jones scenario provided in the homework Word file.
## Part 2: Daysheet
Use the additional forms and patient encounter forms to complete the daysheet portion of the homework word file for all four patients (Ben Jones, Ross Parker, Darla Sissle, and Amanda Chin.)
Ben Jones's information scenario found on the assignment file includes all three DOS (dates of service).
Encounter forms for all 3 patients:
[Ross Parker, Darla Sissle, Amanda Chin](https://content.grantham.edu/academics/GU_AH214b/W3AEncounterForms.pdf)
## Part 3: Insurance Claim Registry
Include an Insurance Claim Registry that includes the insurance claims for all four patients listed under Part 2.
· Ben Jones – three entries
· Ross Parker – one entry
· Darla Sissle – one entry
· Amanda Chin – one entry
### Objective:
· Model the process for tracking finances in a medical office.
· Interpret an encounter form and a chargemaster.
**## WK3ASSIGNMENTHP-2141.docx**
**WK3 ASSIGNMENT HP-214**
**Tracking Finances**
This week we looked at Revenue Cycle Management with an emphasis on tracking patient services, charges, payments, and adjustments. Your homework assignment is to complete three of the forms that you may use as a billing specialist.
There are a total of 87 entries for you to complete. The assignment score will reflect the number of correct entries made.
Use the assignment document to complete
## Tracking Finances – W3A INFORMATION
This week we looked at Revenue Cycle Management with an emphasis on tracking patient services, charges, payments, and adjustments. Your homework assignment is to complete three of the forms that you may use as a billing specialist.
There are a total of 87 entries for you to complete. The assignment score will reflect the number of correct entries made.
**Include the following aspects in the assignment:**
Download and open:
[Week 3 Homework](https://content.grantham.edu/academics/GU_AH214b/W3Homework.docx). Follow the instructions to complete the work and submit the file as your homework assignment.
## Part 1: Patient Ledger
Complete the patient ledger for the Ben Jones scenario provided in the homework Word file.
## Part 2: Daysheet
Use the additional forms and patient encounter forms to complete the daysheet portion of the homework word file for all four patients (Ben Jones, Ross Parker, Darla Sissle, and Amanda Chin.)
Ben Jones's information scenario found on the assignment file includes all three DOS (dates of service).
Encounter forms for all 3 patients:
[Ross Parker, Darla Sissle, Amanda Chin](https://content.grantham.edu/academics/GU_AH214b/W3AEncounterForms.pdf)
## Part 3: Insurance Claim Registry
Include an Insurance Claim Registry that includes the insurance claims for all four patients listed under Part 2.
· Ben Jones – three entries
· Ross Parker – one entry
· Darla Sissle – one entry
· Amanda Chin – one entry
### Objective:
· Model the process for tracking finances in a medical office.
· Interpret an encounter form and a chargemaster.
In-depth study guidance and analytical solution covering Module 6 Diversity.
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– ## SOAPNoteTemplate-1-14.docx **## SOAPNoteTemplate-1-14.docx** | | | | — | — | | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance | | _Demographics_ | | | _Chief Complaint (Reason for seeking health care)_ | | | _History of Present Illness (HPI)_ | | | _Allergies_ | | | _Review of Sy…
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**## SOAPNoteTemplate-1-14.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**## SOAPNoteTemplate-1-14.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
– To assess a clinical issue that is the focus of your Quality Improvement Project. – Create a description of the clinical issue to be addressed in the project. **Content Requirements:** 1. Identify the clinical issue that will be the focus of your Quality Improvement project. 2. Provide rationale f…
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– Create a description of the clinical issue to be addressed in the project.
**Content Requirements:**
1. Identify the clinical issue that will be the focus of your Quality Improvement project.
2. Provide rationale for the need to change the status quo.
3. Identify best practices from the literature related to the issues.
– Discuss the strategies for maintaining a healthy work environment; the legal implications of workplace violence and the responsibilities from organizations in providing a healthy work environment – Review the ANA Bill of Rights (Box 14-1 from your textbook) and discuss how it protects nurses.
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– Review the ANA Bill of Rights (Box 14-1 from your textbook) and discuss how it protects nurses.
The St. Fleur family is well respected in the Haitian community because they are religious, faithfully practice Jehovah's Witness, and have great moral values. Rhonda, the youngest daughter of this family, is 17 years-old and lives at home with her mother and father. Recently, she began having fever…
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Order on TutorsGallery →The St. Fleur family is well respected in the Haitian community because they are religious, faithfully practice Jehovah's Witness, and have great moral values. Rhonda, the youngest daughter of this family, is 17 years-old and lives at home with her mother and father. Recently, she began having fevers and subsequently developed severe abdominal pain. She was admitted to the hospital, where laboratory tests were hCG and COVID-19 positive. Rhonda was in shock when the doctor informed her that she was pregnant and COVID-19 positive. She confessed to the doctor that she has been sneaking out during the Pandemic to see her boyfriend, but swears that she uses sexual prevention techniques. However, as her symptoms have de-compensated, she is rushed to the OR with a diagnosis of Ectopic Pregnancy. The family is at the bedside and reminds the surgical team that Rhonda's faith prevents her from receiving any blood products due to her religion and cultural beliefs.
What are Haitian's views on unplanned pregnancy and viral infections?
What are Haitian's views on blood transfusions?
What are your procedures/responsibilities as a Nurse Anesthetist if the family refuses blood products for Rhonda's emergency surgery?
Clinical change and quality improvement projects are implemented with an aim to make healthcare systems safer and more efficient. How do you know that your specific clinical change project will have this type of an effect on the organization?APA format. minimum 300 words. Due in 6 hrs. topic patient…
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Order on TutorsGallery →Clinical change and quality improvement projects are implemented with an aim to make healthcare systems safer and more efficient. How do you know that your specific clinical change project will have this type of an effect on the organization?APA format. minimum 300 words. Due in 6 hrs.
topic patient handoff report