Attend and participate in OSCE activities. None attendance will result in an incomplete grade. Students cannot be cleared for certification until all incomplete grades are completed.

Complete and submit an outstanding discharge note from an actual patient you cared for during practicum experience.  If you did not have the opportunity of discharge a client during your practicum experience, discuss with your preceptor and formulate the plan to discharge a client to your preceptor.

Discharge Note

 

A Discharge Note a communication between the treating clinician and the next person/agency involve in the care of a client. It is created when a patient’s case is closed and referred to another provider either by discharge from an inpatient or outpatient program or if a patient is deceased. The Discharge Note provides closure between a provider and a client. The closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral discharge note to assist them in practice when a Discharge Note is appropriate. A Discharge Note is a part of the Chart, a legal document and must be treated as such.

Following the information from a patient interview, chart review and/or your preceptor; upload your note or your oral presentation to Blackboard. If you choose a dictated summary it must be verbatim of what would have been written.

NOTE: If you did not have the opportunity of discharging a client in your practicum experience, discuss with your preceptor and formulate the plan to discharge one to your preceptor.

 

 

REASON FOR DISCHARGE NOTE:

 

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSES:  Medical and Psychiatric

REASON FOR ADMISSION: 

HISTORY: Make this brief but significant

PROCEDURES AND TREATMENT:

1. Individual and group psychotherapy. – BE SPECIFIC
   2.  Psychopharmacologic management. – BE SPECIFIC
   3.  Family therapy conducted by social work department with the patient and the patient’s family for the purpose of education and discharge planning.

HOSPITAL COURSE:  Brief discussion of how the hospitalization went. All intervention implemented and client’s response to therapy. 

 

DISCHARGE ASSESSMENT: client current condition at the time of transfer, including mental status exam.

.

ASSETS and LIABILITIES:  this include strengths, weaknesses, support system, and Maslow

 

SHORT TERM GOALS and LONG-TERM GOALS: determined by staff with patient input, address each goal and progress toward that goal

 

DISCHARGE PLAN:  The risk for harm, medications, labs, teaching, labs, referrals, and follow-ups.  All transfer information as arranged by case manager and social work

Transfer Note

 

A Transfer Note is created when a patient’s case is being transferred to another facility for various reasons and referred to another provider either by change of level of care, type of care required, decision by insurance, decision by family, or change of program; to mention but a few.  As the provider, you may be okay with this transition and sometimes not, but you must provide the necessary information whether you are in support of this transition or not. Transfer note is a communication between the treating clinician and the next provider/agency involved. The Transfer Note provides closure on your part as the provider, but not for the patient. The closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral transfer note to assist them in practice when a Transfer Note is appropriate. A Transfer Note is a part of the Patient Chart, a legal document and is to be treated as such.

 

Following the information from a patient interview, chart review and/or your preceptor; upload your note or your oral presentation to Blackboard. If you choose a dictated summary it must be verbatim of what would have been written.

NOTE: If you did not have the opportunity of transferring a client in your practicum experience, discuss with your preceptor and formulate the plan to transfer a client to your preceptor.

 

 

DEMOGRAPHICS

 

REASON FOR TRANSFER NOTE:

 

DATE OF ADMISSION:  

DATE OF TRANSFER:  

TRANSFER DIAGNOSES:  Include Medical and Psychiatric

REASON FOR ADMISSION: 

HISTORY:

PROCEDURES AND TREATMENT:

1. Individual and group psychotherapy. – BE SPECIFIC
   2.  Psychopharmacologic management. – BE SPECIFIC
   3.  Family therapy conducted by social work department with the patient and the patient’s family for the purpose of education and discharge planning.

HOSPITAL COURSE:  Brief discussion of how the hospitalization went. All intervention implemented and client’s response to therapy. 

 

TRANSFER ASSESSMENT:  client current condition at the time of transfer, including mental status exam.

ASSETS and LIABILITIES:  this include strengths, weaknesses, support system, and Maslow

 

SHORT TERM GOALS and LONG-TERM GOALS:

 

TRANSFER PLAN:  The risk for harm, medications, labs, teaching, labs, referrals, and follow-ups.  All transfer information as arranged by case manager and social work. 

SOAP NOTE

 

A SOAP note for psychiatry is a little different than a SOAP note for a medical patient, but the basic format and premise is the same.  It is a communication between the treating clinician and the next treating clinician as well as other members of the care team. It is also something that the insurance company or payor source may want to look at to determine if the patient requires this level of care. A SOAP note is a part of the Chart, a legal document, and is to be treated as such. It is not the initial documentation on a patient, it is after the patient has been seen and an initial psychiatric evaluation has been done.

 

This is a pretty good example for you to use for preparing a SOAP NOTE. If your facility uses one you like better, that is fine. Following the information from a patient interview, a chart review; upload your note to Blackboard as directed.

 

 

SOAP NOTES:

Date and Time

Name and Credentials of person writing this note:

ALSO LIST MEDS AND DOSES on a separate sheet as if on a MAR

Significant Events:   Over past 24 hours

Subjective (S):               Use the patient’s own words as much as possible

• Vegetative symptoms (sleep, appetite, concentration/energy, anxiety, etc.)
• Patient’s complaints, pain, medication side effects
• Requests

 

Objective (O):

• Labs (admit labs of first day, new results, or new labs ordered)
• Studies (CXR, ECG, US, neuropsychological testing, etc.)

 

MENTAL STATUS EXAM (MSE):

Appearance

Behavior

Speech

Mood

Affect

Thought Process

Thought Content

Insight

Judgment

Cognition

Assessment (A):  1-2 sentence summary of

• Patient profile: age, M/F, race, occupation, marital status
• Diagnosis differential
• Diagnosis: Psychiatric and Medical
• Prognosis
• Treatment and tolerance, side effects, improvement

 

Plan (P):       List by diagnosis or problem (medication strategy, planned tests, social work issues,

discharge plans)

Journal Assignment – Unit # 3

 

In some states, PMHNPs practice independently; while in some states, PMHNPs will need a supervising physician or a collaborative agreement with a physician to practice. In this journal, to prepare yourself to practice upon graduation, examine the practice requirements in your state.

 

1 page paper:

• Analyze and describe the PMHNP practice agreements in your state.
• Discuss two physician collaboration issues you might encounter as a PMHNP in your state.
• What are the barriers to PMHNPs practicing independently in your state?
• Discuss your plan for how you might address PMHNP practice issues in your state.

Part 1:

1 Page paper:

In your journal responses, please attempt to link your thoughtful responses to the experiences provided in online meetings, your psychotherapeutic readings and the other related materials, as well as what is happening in your day-to-day life. Think about and reflect upon how the ideas discussed and ideas in the readings can be incorporated into your individual practice and develop your reflective entry around this. The purpose of this assignment is to challenge the student to reflect on contextual matter, how this interplay with their future vision of their practice and their interface with barriers to optimal care. Ethical and moral dilemmas may also be a part of your reflection and observations. This is a feeling assignment. Reflect on how you are feeling.

No citation required

Part 2: 

1 page paper:

 

American Nurses Credentialing Center (ANCC) is currently the only option for PMHNPs to obtain the national certification as a PMHNP-BC (across the lifespan). Board certification is not a requirement in all the states for the NP license, but malpractice insurance providers and many health care facilities may require NP board certification as a prerequisite to grant privilege to practice.

• Examine and describe the PMHNP practice restrictions/limitations in your state.
• Describe a clinical practice or professional issues with the licensure and certification.
• Research reimbursement rates for various treatment modalities.
• Compare NP rates to other provider rates.

i-Human Simulated Clinical Experience

Students are required to submit a reflection on Discussion Board and share their experience after completing each case study. Reflection is worth 5 of 15% on each assignment. Reflections should include answers to the following questions:

In 2 and more pages,

1. What is the Chief Complain in this case study? What are important questions to ask the patient to formulate the HPI?
2. What components of the examination are important to review in this case? What are pertinent positive and negative findings to help you formulate your diagnosis?
3. Which differential diagnosis is to be considered with this case study? What was your final diagnosis?
4. What was your treatment plan? Provide evidenced-base practice article or treatment guideline for your chosen plan.
5. Any other feedbacks, including difficulty navigating the system and the case.

• Respond to at least two peers post on two different days.

Discussion:  Initial discussion

• Select one disorder from the list of disorders on this unit readings.
  • OCD & related disorders
  • Trauma & stressor related disorders
  • Dissociative Disorders
  • Psychosomatic medicine
  • Sleep disorder
  • Eating Disorders

   

  • Explain the diagnostic criteria for your selected disorder.
  • Describe clinical features from a client that led you to believe this client had this disorder. Align the clinical features with the DSM-5 criteria.
  •  Explain the evidenced-based psychotherapy and psychopharmacologic treatment for your selected disorder.
  • List two differential diagnosis for the disorder selected
  • Support your rationale with references from your reading resources or other evidence-based academic resources.

   

Respond to at least two peers post on two different days.

 

Discussion:  Initial discussion

 

In this discussion, students will analyze the differences between two disorders from either schizophrenia, anxiety or bipolar family. Options to select from:

Schizophrenia and Schizo affective disorder

PTSD and Generalized Anxiety Disorder

Bipolar 1 disorder and Bipolar 11 disorder.

 

• Explain the differences between the disorders you selected.
• Explain the diagnostic criteria for each of the disorders
• Discuss the evidence-based treatments for your selected disorders
• Support your rationale with evidence-based references

• Respond to at least two peers post different from the disorders you selected on two different days.

Discussion: Initial discussion

Introduce yourself to the class; include your education, work experience, hobbies or something we need to know about you. Briefly discuss what you anticipate to gain upon completion of this class and how you will use the knowledge to make social change.

In a 2-3 page paper,

PMHNPs use rating scales for reasons such as screening, collection of information, standardization of data, tracking changes, measuring severity, and formal evaluation of performance. Select a standardized measurement scales for psychiatric practice and briefly summarizes the scale, including the purpose, reliability, internal consistency, and validity. Use evidence-based research to support your data.

Refer to the grading rubric for requirements, including the evidence-based references.

Respond to at least two peers post on two different days.