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Pychiatric Patient Evaluation

Pychiatric Patient Evaluation

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  Use the following case template to complete Week 2 Assignment 1. On page 5, assign DSM-5-TR and Updated ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit them together as one document.

Identifying Information

Identification was verified by stating their name and date of birth.

Time spent for evaluation: 0900am-0957am

Chief Complaint

“My other provider retired. I don’t think I’m doing so well.”


25 25-year-old Russian female evaluated for psychiatric evaluation was referred by her retiring practitioner for PTSD, ADHD, and Stimulant Use Disorder in remission. She has currently prescribed fluoxetine 20mg po daily for PTSD and atomoxetine 80mg po for ADHD.

Today, the client denied symptoms of depression, anergia, anhedonia, motivation, no anxiety, frequent worry, feeling restlessness, no reported panic symptoms, and no reported obsessive/compulsive behaviors. The client denies active SI/HI ideations, plans, or intent. There is no evidence of psychosis or delusional thinking. The client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. The client reports increased irritability and is easily frustrated, loses things quickly, makes mistakes, and has a hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs, reports nightmares of a previous rape, isolates, fearful of going outside, has missed several days of work, appetite decreased. She has bodily concerns with GI upset and headaches. The client denied any current binging/purging behaviors, withholding food from themself, or engaging in anorexic behaviors. No self-mutilation behaviors.

Diagnostic Screening Results

Screen of symptoms in the past two weeks:

PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7 = 2 with symptoms rated as no difficulty in functioning
Interpreting the Total Score:
Total Score Interpretation ≥10 Possible diagnoses of GAD; confirm by further evaluation 5 Mild Anxiety 10 Moderate anxiety 15 Severe anxiety

MDQ screen negative

PCL-5 Screen 32

Past Psychiatric and Substance Use Treatment

·         Entered mental health system when she was age 19 after being raped by a stranger during a house burglary.

·         Previous Psychiatric Hospitalizations:  Denied

·         Previous Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015

·         Previous psychotropic medication trials: sertraline (became suicidal), trazodone (worsened nightmares), bupropion (became suicidal), Adderall (began abusing)

·         Previous mental health diagnosis per client/medical record: GAD, Unspecified Trauma, PTSD, Stimulant use disorder, ADHD confirmed by school records

Substance Use History

Have you used/abused any of the following (include frequency/amt/last use):

Substance Y/N Frequency/Last Use
Tobacco products Y ½
ETOH Y last drink two weeks ago, reports drinks 1-2 times monthly, one drink socially
Cannabis N
Cocaine Y last use 2015
Prescription stimulants Y last use 2015
Methamphetamine N
Inhalants N
Sedative/sleeping pills N
Hallucinogens N
Street Opioids N
Prescription opioids N
Other: specify (spice, K2, bath salts, etc.) Y reports one-time ecstasy use in 2015

Any history of substance-related:

·         Blackouts:  +

·         Tremors:   –

·         DUI: –

·         D/T’s: –

·         Seizures: –

Most extended sobriety reported since 2015—stayed sober, maintaining sponsor, sober friends, and meetings.

Psychosocial History

The adoptive parents have raised the client since age 6 in a Russian orphanage. She has unknown siblings. She is single and has no children.

Employed at a local tanning bed salon

Education: High School Diploma

Denied current legal issues.

Suicide / Homicide Risk Assessment


·         Suicidal Ideas or plans – no

·         Suicide gestures in the past – no

·         Psychiatric diagnosis – yes

·         Physical Illness (chronic, medical) – no

·         Childhood trauma – yes

·         Cognition not intact – no

·         Support system – yes

·         Unemployment – no

·         Stressful life events – yes

·         Physical abuse – yes

·         Sexual abuse – yes

·         Family history of suicide – unknown

·         Family history of mental illness – unknown

·         Hopelessness – no

·         Gender – Female

·         Marital status – single

·         White race

·         Access to means

·         Substance abuse – in remission


·         Absence of psychosis – yes

·         Access to adequate health care – yes

·         Advice & help-seeking – yes

·         Resourcefulness/Survival skills – yes

·         Children – no

·         Sense of responsibility – yes

·         Pregnancy – no; last menses one week ago, has Norplant

·         Spirituality – yes

·         Life satisfaction – “fair amount”

·         Positive coping skills – yes

·         Positive social support – yes

·         Positive therapeutic relationship – yes

·         Future-oriented – yes

Suicide Inquiry: Denies active suicidal ideations, intentions, or plans. Denies recent self-harm behavior. Talks futuristically. Denied history of suicidal/homicidal ideation/gestures; denied history of self-mutilation behaviors

Global Suicide Risk Assessment: The client is found to be at low risk of suicide or violence. However, the risk of lethality increased under the context of drugs/alcohol.

No required SAFETY PLAN related to low-risk

Mental Status Examination

She is a 25-year-old Russian female who looks her stated age. She is cooperative with the examiner. She is neatly groomed and clean and dressed appropriately. There is mild psychomotor restlessness. Her speech is clear, coherent, and regular in volume and tone, and she has a culturally solid accent. Her thought process is meditative. There is no evidence of looseness of association or flight of ideas. Her mood is anxious and mildly irritable, and her affect is appropriate to her mood. She was appropriately smiling at times. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, She is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is fair. Her insight is good.

Clinical Impression

The client is a 25-year-old Russian female who presents with a history of treatment for PTSD, ADHD, and Stimulant use Disorder in remission.

Moods are anxious and irritable. She has ongoing reported symptoms of re-experiencing, avoidance, and hyperarousal of her past trauma experiences; ongoing subsyndromal symptoms related to her past ADHD diagnosis and exacerbated by her PTSD diagnosis. She denied vegetative symptoms of depression, no evident mania/hypomania, no psychosis, and denied anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no withdrawal symptoms, and has somatic concerns of GI upset and headaches.

At the time of disposition, the client adamantly denies SI/HI ideations, plans, or intent, can determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is at low risk for self-harm based on her current clinical presentation and her risk and protective factors.



PTSD 313.89 (F94.1)

ADHD 314.01 (F90.2)

Stimulant Use Disorder, in remission 305.10 (F15.21)

Treatment Plan

1)     Medication:

·         Increase fluoxetine 40mg po daily for PTSD #30 1 RF

·         Continue with atomoxetine 80mg po daily for ADHD. #30 1 RF

Instructed to call and report any adverse reactions.

Future Plan: monitor for decreased re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, fewer mistakes, less forgetful

2)      Education: Risks and benefits of medications, including non-treatment, are discussed. Potential side effects of medications discussed. Verbal informed consent was obtained.

Not to drive or operate dangerous machinery if feeling sedated.

Not to stop medication abruptly without discussing it with providers.

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and Encouraged ongoing abstinence. Maintain support system, sponsors, and meetings.

Discussed how drugs/ETOH affect mental health, physical health, and sleep architecture.

3) The patient was educated about the therapy and services of the MHC, including emergent care. The referral was sent via email to the therapy team for PET treatment.

4) The patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, and the MHC Crisis Clinic. The patient was instructed to go to the nearest ER or call 911 if they became actively suicidal and homicidal.

5)      Time allowed for questions and answers provided. Provided supportive listening. The patient appeared to understand the discussion and appeared to have the capacity for decision-making via verbal conversation.

6)      RTC in 30 days

7)      Follow up with PCP for GI upset and headaches; review PCP history and physical dated one week ago and include lab results

The patient is amenable to this Plan and agrees to follow the treatment regimen as discussed.

Narrative Answers

Information Required in Documentation to Support DSM-5 and ICD-10 Coding

Psychiatrists should take a comprehensive patient history to facilitate DSM-5 coding and ICD-10 coding. Relevant information that should be captured includes the patient’s chief complaint, past medical history, social history, family history, physical examination, and the care plan (Knopf, 2022). Proper documentation of the presenting complaint enables the healthcare provider to make an accurate clinical impression and diagnosis. Furthermore, accurate documentation of the presenting complaint forms the basis for formulating the best ICD-10 coding structure (Knopf, 2022). In this context, the patient’s PTSD and ADHD are assigned codes F94.1 and F90.2, respectively. This is harmonious with the ICD-10 coding system, which assigns F90 to F99 for ADHD and other conduct disorders (Knopf, 2022).

Similarly, the patient’s stimulant use disorder is assigned F15.21. This is consistent with ICD coding, which assigns codes F10 to F19 for substance use-related disorders (Knopf, 2022). A proper understanding of ICD-10 facilitates exhaustive documentation, hence improved reimbursements. Additionally, psychiatrists and other healthcare providers should understand the policies and guidelines of their insurers related to various mental health disorders (Knopf, 2022).

Pertinent Documentation Missing from the Case Scenario

The case scenario lacks detailed information on physical and systemic evaluation and medical and family history. System evaluation is a crucial component of history-taking. It allows the psychiatrist to recognize both recent and past signs and symptoms that may be connected to the psychiatric condition (Scher, 2018). Additional symptoms that might not have been noted in the presenting history can be found with a thorough patient evaluation. For instance, it can assist in identifying variables that worsen the disease and those that lessen its symptoms (Scher, 2018). It also allows the psychiatrist to delve further and find any comorbidities. Some comorbidities can worsen the prognosis of psychiatric problems. For example, a psychiatric patient with a migraine is likely to have sleep disturbances caused by headaches. As such, insomnia would worsen the patient’s mental health condition. (Burch et al., 2021).

Detailed family history is essential since it aids in identifying a genetic connection to the psychiatric condition. Findings indicate that the likelihood of developing a psychiatric problem is increased by having a first-degree relative with the condition. For instance, persons with first-degree relatives who have schizophrenia have a ten percent increased chance of having the disease (McCutcheon et al., 2020). A comprehensive medical history helps to identify and exclude differential diagnoses. By so doing, pertinent treatment plans with better patient outcomes are adopted.

How to Improve Documentation to Support Coding and Billing for Maximum Reimbursement

All healthcare facilities should embrace proper documentation. Proper documentation helps to avert medical and billing errors. As such, the incidence of adverse events, toxicities, sub-optimal outcomes, and reduced profits is averted. Accurate billing increases reimbursements from insurers. Various strategies can be used to optimize documentation. Firstly, healthcare facilities should formulate elaborate practice guidelines and policies regarding documentation. These guidelines should be evidence-based. Such guidelines will improve documentation accuracy by creating uniformity in task execution (Drella, 2020). The second strategy is implementing SOAP documentation. This type of documentation directs healthcare practitioners to capture the patient’s subjective and objective data to assess and develop the best treatment plan (Drella, 2020). The third strategy is the effective use of electronic health record (EHR) systems. Electronic health record systems can help to improve documentation using computerized physician order systems (Fragidis & Chatzoglou, 2018).

Furthermore, EHR systems promote interdisciplinary collaboration to improve the accuracy of documented data. This is possible because EHR systems enable interdisciplinary team members to access patient information promptly. Members of the interdisciplinary team should receive periodic training on SOAP documentation, existing practice guidelines, and appropriate use of EHR systems.


Burch, R., Rizzoli, P., & Loder, E. (2021). The prevalence and impact of migraine and severe headache in the United States: Updated age, sex, and socioeconomic-specific estimates from government health surveys. Headache, 61(1), 60–68.

Drella, M. (2020). Critical Strategies for Improving Clinical Documentation in 2020. Retrieved from

Fragidis, L. L., & Chatzoglou, P. D. (2018). Implementation of a nationwide electronic health record (EHR): The international experience in 13 countries. International Journal of Health Care Quality Assurance, 31(2), 116–130.

Knopf, A. (2022). DSM revisions: Updates for racial/gender concepts, ASD, NSSI, DMDD, and PTSD. The Brown University Child and Adolescent Behavior Letter, 38(6), 9-10.

Scher, L. M. (2018). Psychiatric Interview. Retrieved from


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Assign DSM-5-TR and ICD-10 codes to services based on the patient case scenario.
Then, in 1–2 pages, address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit them all together as one document.

Pychiatric Patient Evaluation

Pychiatric Patient Evaluation

Explain what pertinent information, generally, is required in documentation to support DSM-5-TR and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

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