I: CM guided client through ISP goals. CM inquired about client’s upcoming LAMP VASH appointments. CM discussed and encouraged client to get his driver’s license. CM praised client for being honest regarding drug use but also encourage sobriety. CM administered Beck Depression Inventory and review results.
She was disoriented to time, place or time. Client appears to be decompensating. Client missed two scheduled appointments at Woodhull Hospital one for the podiatrist and the other one with the Geriatric doctor, due to client foot deformity she required onsite transportation and an escort back and forth to every doctor’s appointments. Unfortunately due to residents move out and housing tours, client transportation request was cancel.
The claimant is an 18- year old filing a continuing disability review alleging depression and anxiety. The claimant has a history of anxiety and depression. She completed the SSA 3368 on 7/18/16 and indicated on the form she had not seen anyone for mental health but had a visit scheduled on 7/19/16. The DDS was unable to obtain additional information regarding the claimant’s conditions.
Doctor Karim: In short term I can offer you medication but in the long term maybe it will be helpful if I referred you to a councillor. I would like you to make another appointment to view the situation but if you have any further concerns in the mean time please come and see me sooner. Yasmin: Yes that would be helpful and thank you for listening.
Talk about what went well in the scenario. I perform vitals sings and communicated effectively with Mr. Ahmed. I educated the patient in areas such as dehydration, fall risks, intake and ouptup measurements. In addition, I administer oral and intravenous medication to ensure proper drug
Limitations recognised throughout the SDM process were related to risk of further deterioration in the Consumer’s mental state. As the Consumer was slowly taken off his medications, in a safe clinical manner, his presentation deteriorated. The Consumer’s sleep pattern worsened due to the elevation in his mood, there was a noted increase in impulsivity and poor boundaries with others on the inpatient unit, leading to the Consumer becoming vulnerable. There was a prominent increase in erratic and aggressive towards others, leading to the assault of a staff member on the inpatient unit and subsequently required the use of restrictive interventions. The decline in mental state resulted in the Consumer’s father, case manager and treating team coming together for a family meeting with the Consumer present in which the previous medications the Consumer had been previously prescribed were recommenced in an attempt to re-stabilise his presentation, unfortunately this was a substituted decision made by the consumer’s father and treating tream.
1. Have began the process of updating the forms for Psychiatric Evaluations as well as the forms to document follow-ups visits (Medication Management). The purpose is to improve the flow of information, simplify its use, assure the appropriate content, and facilitate arriving to the appropriate billing codes. 2. Met with all extended providers, as well as doctors to continue to ensure consistency in the delivery of quality care and the utilization of best practices, Participation in the MACRA/MIPS on a weekly basis 3.
D: Client was on time for intake appointment. Together, discussed the assessment recommendation and barriers to successful treatment outcomes. Client reviewed and signed of all treatment admission paperwork, including treatment agreement, ROIs, THS treatment policies, THS alcohol drug Services patient rights, THS patient responsibilities, THS health and safety information, THS counselor disclosure information, patient grievance procedures, THS HIV/AIDS information, THS notice of privacy practices, referral to Quit smoking, and marijuana policy. Treatment plan was developed, which was focused on Dim 4, 5, and 6; focusing on developing readiness to change, identifying relapse potential, and building a strong family and social support system.
R: Client presented well groomed and calm. His mood was euthymic, and his affect was within normal limits. Client’s thought processing was goal directed and coherent while being instructed on LAMP VASH referral. Client reported being worried about meeting his VA claim appeal dateline.
SC placed call to Pa and spoke with Bill Pa’s spouse who reported that doing ok. But she has come combative lately and verbal abusive. Bill spoke at length about her behavior and the impact it has on him. Bill is offended when Pa makes disparaging remarks about him and calls him out of his name. Bill reported that he believes Pa needs a medication review and a change in meds.
She must understand the doctor's instructions and the patient's concerns. Her communications skills focus on both giving and receiving information as well as creating an environment of confidence. Some consequences of ineffective communication can be chaos, confusion, disorder, fear, conflict, inefficient systems, and wasted resources (Vertino, 2014). An ineffective communication can lead to errors in patient’s misdiagnosis and even medication on admission, during hospital stay, and after discharge, and whether these errors were potentially harmful.
Dr. Keith requested a mental health evaluation on a Mr. Alewine. He is a 28 year old male who presented to the ED via EMS for chest pains, suicidal ideation, and symptoms of psychosis. Mr. Alewine reported arriving in Siler City from Tennessee after a 16 hour bus trip. He reports after his 16 hour trip, he went to a mechanic shop to call 911 for chest pain and suicidal ideation without a plan after stressing about having a place to stake for a few days. Per documentation Mr. Alewine was asked about current chest pain on a scale of 1 to 10, he reports a 1.