see below

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective

Verify Patient

Name:Willie

DOB: 67years old (specifice date not provided).

Minor: NA

Accompanied by: self

Demographic: NA

Gender Identifier Note:Male

CC: “I hear voices in my head telling me to do bad things, and I have trouble distinguishing what’s real and what’s not. I also feel very sad and hopeless most of the time, and I’ve lost interest in things I used to enjoy”.

HPI: Willie a 67years old male presents with a history of auditory hallucinations and delusions. He reports hearing multiple voices in his head that tell him to harm himself and others. He also has difficulty distinguishing these voices from reality. Additionally, he reports feeling sad and hopeless most of the time, with decreased appetite and difficulty sleeping. He also reports to have lost interest in activities he previously enjoyed. The patient has been previously diagnosed with schizophrenia and pschizoaffective disorder, but his symptoms have not improved with previous treatment. The patient’s symptoms have been present all along and have gradually worsened over the time

Patient has been hallucinating. The patient has nomal thought process.

SI/ HI/ AV: patient shows signs of suicidal ideation.

Allergies: NKDFA.

(medication & food)

Past Medical Hx: adherence

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: schizophrenia and pschizoaffective disorder

Describes stable course of illness.

Previous medication trials: not reported

Safety concerns:

History of Violence
to Self:suicidal

History of Violence t
o Others: none reported

Auditory Hallucinations:reported

Mental health treatment history discussed:

History of outpatient treatment: reported

Previous psychiatric hospitalizations: reported

Priorsubstance abuse treatment: not reported

Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).

Substance Use: not reported

Client does report abuse of or dependence on alcohol.

Current Medications: Benztropine

(Contraceptives):

Supplements:

Past Psych Med Trials: schizophrenia

Family Medical Hx: not reported

Family Psychiatric Hx: not reported

Substance use –NKDA

Suicides-not reported

Psychiatric diagnoses/hospitalization-not reported

Developmental diagnoses

Social History:

Occupational History: currently unemployed.

Military service History:Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues,no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: no fever reported.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: reports abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness.

Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Objective

Vital Signs: Stable

Temp:96.9
BP:130/98
HR:68
R:22
O2:100
BMI:

LABS:
Lab findings nomal Hepatic function
Tox screen: negative
Alcohol: negative
HCG: N/A

Physical Exam:
MSE:
Patient is fully oriented AAOX3. Patient is dressed appropriately for age and season. Psychomotor activity appears impaired.
Presents with incoherent speech and improper judgement, spontaenous, normal rate.
TC: no abnormal content elicited, denies suicidal ideation and denieshomicidal ideation. Process appears linear, coherent, goal-directed.
Cognition distorted with difficulty attending to topicsattention span & concentration and average fund of knowledge.
Judgment appears impaired . Insight appearsimpaired

The patient seems disturbed, and her insights and judgements seems impaired. Patient is able and willing to take part in the planning of their care, disposition, and discharge.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: – schizophrenia ICD-10 is F20

Dx: schizoaffective disorder ICD-10-CM Code F25

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Psychiatric. NKDA

Estimated stay

Safety Risk/Plan: Guidelines for managing violent or aggressive behavior: This may include training for caregivers and family members on how to de-escalate situations and provide appropriate support. Monitoring for suicidal thoughts and behaviors: Caregivers and family members should be trained to recognize the signs of suicidal thoughts and behaviors and take appropriate action.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

The patient is put on chlorpromazine Oral: 500 mg orally per day Maximum dose: 2000 mg/day until he stablizes.

Pharmacologic interventions for schizophrenia and schizoaffective disorder typically include the use of antipsychotic medications. These medications work by regulating the levels of certain chemicals in the brain, called neurotransmitters, which can help to reduce symptoms such as delusions and hallucinations (Olmos, et al., 2019). The most commonly used antipsychotic medications include: First-generation (typical) antipsychotics: such as haloperidol (Haldol) and chlorpromazine (Thorazine) Second-generation (atypical) antipsychotics: such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), and clozapine (Clozaril) Dosage, route, and frequency of these medications will vary depending on the individual and their specific condition. It’s important to work with a healthcare provider to find the right dosage and schedule that works best for you.

In addition to pharmacologic interventions, non-pharmacologic interventions can also be helpful for managing schizophrenia and schizoaffective disorder. These may include: Psychotherapy: such as cognitive-behavioral therapy (CBT) or family therapy Vocational rehabilitation: to help the person return to work or improve their job skills Social skills training: to help the person improve their ability to interact with others Support groups: to provide the person with a sense of community and emotional support Self-help techniques: such as mindfulness, meditation and yoga (Hartman, et al., 2019). It’s important to note that a combination of pharmacologic and non-pharmacologic interventions can be more effective than either one alone. It’s important to work with a healthcare provider to develop an individualized treatment plan that takes into account the person’s specific needs and goals.

The patient is educated on the coping skills and hoiw to take the medication as instructed.

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks

☒>50% time spent counseling/coordination of care.

Time spent in Psychotherapy minutes

Visit lasted minutes

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NAME, TITLE

Date: Time: