MRU PMHNP Clinical Write-Up
Student Name:
Write Up #
Typhon Case #
Semester/Year:
Course:
Chief Complaint
| What brought you here today…? (Put this in quotes.) | “ |
History of Present Illness
| Depression symptoms: Can you describe your depression symptoms? What makes the depression better, what makes the depression worse? Does the depression, come and go? | |
| Anxiety: Does the anxiety come and go or is there all the time? Does anything make the anxiety worse or better? Do you go into panic? If so, how often and how long does it usually last? | |
| Mood swings: Do your moods go up and down? If so, can you tell me more about a typical mood swing? |
|
| Anger/irritability: Do you get angry more than you should? How do you act when you get angry? | |
| Attention and focus: Do you have trouble concentrating or staying on track? | |
| Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself? | |
| Hallucinations: Do you ever hear or see anything that other people may not hear and/or see? | |
| Paranoia: Do you feel like people are talking about your or following you? | |
| Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? Once you get to sleep, do you stay asleep all night or are you up and down throughout the night? |
Past Psychiatric History
| At what age did the mood symptoms start? | |
| Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis? | |
| Where there any environmental factors that could have contributed to the moods? For example, divorce, death in the family, etc. | |
| Any previous treatment and if so, what was it and did it work? List any previous psychiatric medications have been tried and why the medication was stopped. |
Family History
| Include parents, siblings, grandparents if applicable/known; pertinent mental health history. |
Personal/Social History
| Education, marital status, occupation, work history, and legal history |
Substance Abuse History
| Do you currently or in the past used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used? | |
| Do you currently or in the past had an issue with alcohol abuse? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past? | |
| Do you currently smoke cigarettes or vape? | |
| Do you smoke marijuana? |
Medical History
| Medical problems | |
| Previous surgeries |
Mental Status Exam
Appearance and Behavior
| Appearance: Gait, posture, clothes, grooming | |
| Behaviors: mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions | |
| Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive | |
| Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating | |
| Orientation: “What is your full name?” “Where are we at (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?” | |
| Rapport |
Speech
| Quantity descriptors: talkative, spontaneous, expansive, paucity, poverty. | |
| Rate: fast, slow, normal, pressured | |
| Volume (tone): loud, soft, monotone, weak, strong | |
| Fluency and rhythm: slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic |
Affect and Mood
| Mood (how the person tells you they’re feeling): “How are you feeling?” | |
| Affect (what you observe): appropriateness to situation, consistency with mood, congruency with thought content
· Fluctuations: labile, even, expansive · Range: broad, restricted · Intensity: blunted, flat, normal, hyper-energized · Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable |
|
| Congruency: congruent or not congruent mood? |
Perception
| Paranoia | |
| Auditory hallucinations | |
| Visual hallucinations |
Thought Content
| Suicidal | |
| Homicidal | |
| Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)
· Delusions are fixed, false beliefs. · These are unshakable beliefs that are held despite evidence against it, and despite the fact that there is no logical support for it. · Is there a delusional belief system that supports the delusion? |
|
| If not a delusion, then could it be an overvalued idea (an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. – the person is able to acknowledge the possibility that the belief is false)? | |
| Ideas of Reference (IOR): everything one perceives in the world relates to one’s own destiny (e.g., thinking the computer or TV is sending messages or hints). | |
| First rank symptoms: auditory hallucinations, thought withdrawal, insertion and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings or actions experienced as made or influenced by external agents | |
| What is actually being said? Does the content contain delusions? | |
| Are the thoughts ego-dystonic or ego-syntonic? |
Thought Form/Process
| What is the logic, relevance, organization, flow, and coherence of thought in response to general questioning during the interview? | |
| Descriptors: linear, goal-directed, circumstantial, tangential, loose associations, clang associations, incoherent, evasive, racing, blocking, perseveration, neologisms. |
Cognition
| Cognitive testing | |
| Education level |
Insight
| What is their understanding of the world around them and their illness? | |
| Are they able to do reality-testing (i.e., are they able to see the situation as it really is)? | |
| Are they help-seeking? Help-rejecting? |
Judgement
| What have their actions been? Have they done anything to put themselves or other people at harm? | |
| Are they behaving in a way that is motivated by perceptual disturbances or paranoia? | |
| What is your confidence in their decision making? |
Medications
| Medical medications (list) | |
| Psychiatric medications (list) |
Psychiatric Medication
Use this template of this table for each medication. Try to use your own words. For example, how would you explain this information to them or their family?
| Brand/generic name | |
| Dose at the time of visit | |
| Starting dose | |
| How does this medication work? | |
| Major side effects | |
| Is this medication FDA approved for why the person is using this medication? | |
| Patient education | |
| Medication class |
Psychiatric Diagnosis
| Current diagnosis | |
| DSM-5 symptom criteria for each diagnosis (write out DSM-5 symptom criteria) | |
| Did they display/state any symptoms that match the diagnosis? |
Billing/Coding
| ICD 10 Code | |
| Billing Code |
Treatment Plan
| Medication changes made during visit | |
| Clinical impression | |
| Recommended therapy/support sources for person and the reason why | |
| Next visit scheduled |
It looks like you’re requesting assistance in drafting a clinical write-up for a psychiatric mental health nurse practitioner (PMHNP) case study. Due to the extensive nature of the content and specific details required, I’ll outline the general structure and key sections typically included in such a document:
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**MRU PMHNP Clinical Write-Up**
**Student Name:** [Your Name]
**Write Up #:**
**Typhon Case #:**
**Semester/Year:**
**Course:**
—
**Chief Complaint**
“What brought you here today…?”
—
**History of Present Illness**
– **Depression Symptoms:** Describe the patient’s depression symptoms, triggers, and fluctuations.
– **Anxiety:** Explore the nature of anxiety (chronic vs. situational), triggers, and impact.
– **Mood Swings:** Document patterns of mood fluctuations and their impact on daily functioning.
– **Anger/Irritability:** Assess the frequency and expression of anger episodes.
– **Attention and Focus:** Evaluate difficulties in concentration and task completion.
– **Current Self-harm, Suicidal/Homicidal Ideations:** Screen for thoughts of self-harm or harm to others, including presence of a plan.
– **Hallucinations and Paranoia:** Inquire about auditory/visual hallucinations and paranoid thoughts.
– **Sleep:** Assess sleep disturbances, including onset, maintenance, and quality.
—
**Past Psychiatric History**
– **Onset of Mood Symptoms:** Age of initial mood symptom onset.
– **Previous Psychiatric Diagnoses:** Detail any prior diagnoses and circumstances surrounding diagnosis.
– **Environmental Factors:** Identify significant life events influencing mental health.
– **Previous Treatments:** List past therapies and medications, including effectiveness and reasons for discontinuation.
—
**Family History**
– Include relevant mental health history of parents, siblings, and grandparents.
—
**Personal/Social History**
– **Education, Marital Status, Occupation:** Detail current educational and occupational status.
– **Work History:** Outline work-related stressors and adjustments.
– **Legal History:** Note any legal issues impacting mental health or treatment.
—
**Substance Abuse History**
– **Illegal Drugs:** Inquire about past or current illegal drug use.
– **Alcohol:** Assess frequency, quantity, and impact of alcohol consumption.
– **Tobacco and Marijuana Use:** Document smoking or vaping habits.
—
**Medical History**
– **Chronic Medical Problems:** List current medical conditions affecting mental health.
– **Previous Surgeries:** Document past surgical procedures.
—
**Mental Status Exam**
– **Appearance and Behavior:** Describe physical appearance, grooming, and observed behaviors.
– **Attitude and Rapport:** Assess patient’s demeanor, cooperation, and rapport with examiner.
– **Speech:** Evaluate speech patterns in terms of quantity, rate, volume, fluency, and rhythm.
– **Affect and Mood:** Document expressed mood and observed affect, noting fluctuations and congruency.
– **Perception:** Screen for paranoid ideation, auditory/visual hallucinations, and ideas of reference.
– **Thought Content and Form:** Assess thought logic, coherence, organization, and content for delusions or overvalued ideas.
– **Cognition:** Perform cognitive testing and assess educational background.
– **Insight and Judgment:** Evaluate patient’s awareness of illness, reality-testing abilities, and judgment in decision-making.
—
**Medications**
– **Medical Medications:** List current non-psychiatric medications.
– **Psychiatric Medications:** Document current psychiatric medications, including dosages and adherence.
—
**Psychiatric Diagnosis**
– **Current Diagnosis:** Specify primary psychiatric diagnoses based on DSM-5 criteria.
– **DSM-5 Symptom Criteria:** Outline relevant DSM-5 criteria for each diagnosis.
—
**Billing/Coding**
– **ICD-10 Code:** Assign appropriate ICD-10 code for primary diagnosis.
– **Billing Code:** Document relevant billing codes for services rendered.
—
**Treatment Plan**
– **Medication Changes:** Detail any adjustments made to psychiatric medications during the visit.
– **Clinical Impression:** Summarize overall clinical impression based on assessment findings.
– **Therapy/Support Recommendations:** Provide referrals or recommendations for therapy and support services.
– **Follow-Up:** Schedule next follow-up visit and outline objectives for ongoing care.
—
This outline provides a comprehensive structure for organizing the clinical write-up. Ensure that all sections are tailored to the specific case and supported by current APA style citations where applicable.
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