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