Evaluation And Management (E/M)




WAlden University, LLC


Student Name

College of       Nursing-PMHNP, Walden University

NRNP 6675:       PMHNP Care Across the Lifespan II

Faculty Name

Assignment       Due Date 

 Pathways Mental Health 


Psychiatric Patient Evaluation



Use the following case template to complete Week 2   Assignment 1. On page 5, assign DSM-5 and 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 altogether as   one document.


Identifying Information

Identification was verified by stating of 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 yo Russian female evaluated for psychiatric     evaluation referred from her retiring practitioner for PTSD, ADHD,     Stimulant Use Disorder, in remission. She is currently prescribed     fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.

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


Diagnostic Screening Results

Screen of symptoms in the past 2 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 diagnosis 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 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):





Frequency/Last Use


Tobacco       products






last       drink 2 weeks ago, reports drinks 1-2 times monthly one drink       socially 







last use       2015


Prescription       stimulants


last use       2015








Sedative/sleeping       pills






Street       Opioids



Prescription       opioids



Other:       specify (spice, K2, bath salts, etc.)


reports       one-time ecstasy use in 2015

Any history of substance     related: 

· Blackouts: +  

· Tremors:   –

· DUI: – 

· D/T’s: –

· Seizures: – 

Longest sobriety reported     since 2015—stayed sober maintaining sponsor, sober friends, and meetings


Psychosocial History

Client     was raised by adoptive parents since age 6; from Russian orphanage. She has     unknown siblings. She is single; has no children. 

Employed     at local tanning bed salon

Education:     High School Diploma

Denied     current legal issues.


Suicide / HOmicide Risk Assessment


· Suicidal Ideas or plans – no

· Suicide gestures in 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, risk of lethality     increased under context of drugs/alcohol.

No required SAFETY PLAN related to low risk


Mental Status Examination

She is a 25 yo Russian female who looks her     stated age. She is cooperative with examiner. She is neatly groomed and     clean, dressed appropriately. There is mild psychomotor restlessness. Her     speech is clear, coherent, normal in volume and tone, has strong cultural     accent. Her thought process is ruminative. There is no evidence of     looseness of association or flight of ideas. Her mood is anxious, mildly     irritable, and her affect appropriate to her mood. She was smiling at times     in an appropriate manner. 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

Client is a 25 yo Russian female who presents with     history of treatment for PTSD, ADHD, 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, denied     anxiety symptoms. Denied current cravings for drugs/alcohol, exhibits no     withdrawal symptoms, has somatic concerns of GI upset and headaches. 

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


Diagnostic Impression

[Student to provide DSM-5 and ICD-10 coding]

Double click inside this text box to add/edit text.     Delete placeholder text when you add your answers.


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 decrease re-experiencing, hyperarousal, and     avoidance symptoms; monitor for improved concentration, less mistakes, less     forgetful

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

    Not to drive or operate dangerous machinery if feeling sedated.

    Not to stop medication abruptly without discussing 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 affects mental health, physical health, sleep     architecture.

3) Patient was educated about therapy and services of the MHC including     emergent care. Referral was sent via email to therapy team for PET     treatment.

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

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

6) RTC in 30 days 

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


Patient is amenable with this plan and agrees to     follow treatment regimen as discussed. 



Narrative Answers


[In 1-2 pages, address the following:

· Explain   what pertinent information, generally, is required in documentation to   support DSM-5 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.]

Add your answers here. Delete instructions and placeholder   text when you add your answers.



[Add APA-formatted citations for any sources you referenced]

Delete instructions and placeholder text when you add your citations.

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Leadership consists of
various qualities, skills and aspects relating to the action of leading an
organization or a group of individuals (Ennis et al, 2013). The focal point of
the NHS is to enable cultures that provide safe, compassionate and high-quality
care (West et al, 2015). Furthermore, leadership has an impact on a number of
different aspects such as mortality levels, patient satisfaction, staff
well-being, financial performance and generally, the quality of care (West et
al, 2015). The Francis report discussed the importance of distributed
leadership, whereby all healthcare professionals are enabled to think freely,
make decisions and take control themselves. It leads to the provision of
high-quality care (Francis, 2013). This piece of work will assess effective
leadership and why it is a necessity within nursing practice.


Ennis et al (2013) implemented
a study in order to assess the communication characteristics needed for good
leadership within nursing. Interviews were carried out, outlining how effective
communication is key in order to provide high quality care, develop as a
professional and to harbor working relationships (Ennis et al, 2013). The study
produced the following themes: choice of language, listening skills, relevance,
non-verbal communication and relationships. Participants outlined that good
leaders have the knowledge to choose the type of language used and can adapt it
to any scenario that they are faced with. In addition, they suggest that an
effective leader considers the outcome and consequence of each conversation
(for example, whether further support was needed) (Ennis et al, 2013). When
leadership is successful, it enables excellence and ethical and
patient-centered care (Ennis et al, 2013).

Furthermore, it was
noted that good leaders needed to be able to listen, be affable and have
patience (Ennis et al, 2013). One participant outlined that listening should be
first and foremost, valuing its importance and showing great interest in what
the patient has to say (Ennis et al, 2013). Respondents noted the need for
effective communication across all aspects of nursing; with junior staff,
between healthcare professions and when directly caring (Ennis et al, 2013).
Good clinical leaders need to be able to communicate to a high level, adapting
to enable all patients to understand, noting body language, non-verbal cues and
avoiding medically complex terms as much as possible (Ennis et al, 2013). The
study notes the link between effective communication and the amount of
influence that leader has, the team’s performance and their development of
staff member relations (Ennis et al, 2013). Guidelines by NICE also emphasize
the importance of effective communication to enable high quality care (NICE,
2016). Non-verbal communication is also key; effective leaders need to note
their body language and level of eye contact, assessing not only their own
non-verbal cues, but also those of the patient or fellow professional (Ennis et
al, 2013). This will enable them to judge the scenario and to foresee any
issues that may arise (Ennis et al, 2013). Within the study by Ennis et al,
(2013) respondents outlined that good leaders had excellent people skills,
building a good rapport with everyone. To do so, respect and treating each
person as an individual is key (Ennis et al, 2013). It is also vital to ensure
that no judgements are made and that support is offered when needed (Ennis et
al, 2013). Effective leaderships can only be implemented when these areas are
adhered to, building work relationships and providing high quality,
patient-centered care (Ennis et al, 2013).

Emotional intellect

Emotional intellect is
a key aspect to adhere to when managing situations and caring for patients
(Powell et al, 2015). Controlling emotions and self-awareness are both vital
components of emotional intellect (Powell et al, 2015). Doing so decreases the
risk of burnout and ensures that patients are receiving high quality care
(Powell et al, 2015). In addition, being aware of one’s emotions enables a
collaboration that is needed to meet the needs of individuals within the
complex and increasingly technical NHS system (Powell et al, 2015).

The qualities of a leader

The main traits of a
good leader were assessed by Yukl (2013). They consist of a high level of
energy, stress coping mechanisms, confidence, control, maturity, integrity, as
well as being a high achiever, with low needs for affiliation. Nursing leaders
need to be empowering, promote independence, encourage a critical and effective
work environment and remain positive (Jukes, 2013). They should enable fellow
healthcare professionals to build resilience, enabling them to make their own
decisions yet providing protection when needed (Jukes, 2013). In order to
achieve structural change for the provision of high-quality care, the following
should be adhered to: promoting inclusive team work, maintaining trust, seeking
contribution, using personal authenticity, valuing relationships, enabling
learning and challenging any issues that arise (Cleary et al, 2011). Patients
need support and care which cannot be carried out without effective leadership
(Cleary et al, 2011). If a nurse does not show effective leadership skills,
they often retreat towards more traditional methods of behavior (more
documentation and relying on medicine), instead of promoting patient-centered
care (Jukes, 2013). Furthermore, leaders need to support any professionals that
they are responsible for in following the nursing and midwifery code at all
times (Nursing and Midwifery Code, 2015: 18).

The qualities of a manager

Managers oversee a
certain area, supervising fellow staff and ensuring that patient care is
upheld, in addition to administrative aspects (Jukes, 2013). Concerns are
addressed through their specialized nursing experience, good communication and
the ability to take the lead (Jukes, 2013). Good communication is key when
assessing any risks, managing plans, delegating work and ensuring the effective
and safe provision of resources (Jukes, 2013). Delegating work is an integral
part of effectively leading, encouraging active learning, whilst freeing up
more time for aspects that cannot be delegated (Weir-Hughes, 2011). Delegation
is a necessity, especially when staff numbers reduce and pressures rise
(Griffin, 2016). Managers also demonstrate excellent leadership skills by
improving nurse confidence and upholding morale (Timmins, 2011). They need to
ensure that staff are communicating effectively, in order to provide high
quality, safe care (Timmins, 2011). This can be carried out by implementing an
open leadership style, listening to the nurses and involving the team when
making decision (Timmins, 2011). Gilmartin and D’Aunno (2007) outline how nurses prefer managers who are
emotionally intelligent, facilitate change and who actively participate.
Further stating that this leads to cohesion, a sense of empowerment and reduces
stress and burnout (Gilmartin and D’Aunno,
2007). Management and leadership can only be improved by adhering to the
following: ensuring a good set of qualities and knowledge, a supportive environment,
an adequate number of managers and ensuring rewards or acknowledgement for good
practice (World Health Organization, 2007).

Ineffective leadership

Ineffective leadership
can lead to the unsafe provision of care (Nicolson et al, 2011). This was portrayed
during the 1990s, in which nurse Beverly Allitt
murdered children by injecting them with insulin. She was not supervised and
the deaths were not challenged by management (Nicolson et al, 2011). More
recently, the investigation into the Airedale NHS trust found nurse Anne
Grigg-Booth to be providing dangerous care. Many patients died under her care,
which was noted as an abundance of failures in which dangerous actions were not
acknowledged by management (Nicolson et al, 2011). Within the Mid Staffordshire
Foundation Trust, a lack of leadership and supervision detrimentally impacted
upon the lives of many, with high mortality rates (Nicolson et al, 2011). The
Francis Report identified various issues such as, call bells not being
answered, patients lying in their own urine and left without water or food
(Francis, 2013). Saving money was a priority and management preferred to meet
targets than deal with individual needs and thus leadership was poor (Nicolson
et al, 2011). Ineffective management has not only led to unsafe care but cost
more than £16m in legal fees and implementation costs (Calkin, 2013).

Transformational leadership

leadership encourages nurses to provide a high level of care by making
influential changes (Cleary et al, 2011). It involves the following actions:
building trust with fellow healthcare professionals, showing integrity,
inspiring team members, offering intellectual inspiration, adhering to the
needs of each individual and providing support (Malloy and Penprase,
2010). With this leadership style, professionals provide clear aims and a
pathway for their work, prioritising mutual respect,
working together, gaining nurse autonomy and upholding staff morale (Cleary et
al, 2011). Doing so prevents burnout, improves job satisfaction and a sense of
commitment (Cleary et al, 2011). Transformational leadership can be contrasted
with the transactional style in which leaders focus upon meeting targets (it is
not creative, reflective and prevents emotional connection) (Cleary et al,

Support for the transformational leadership

A study was
implemented by Malloy and Penprase (2010) on 122
nurses in order to assess their supervisor’s leadership style. The following
leadership styles were analysed: transactional,
transformational, exceptional-active, exceptional-passive and laissez-faire
(Molloy and Penprase, 2010). The study concluded that
aspects of transformational leadership were connected with 17 out of 37 areas
within the working environment, as calculated by the Copenhagen Psychosocial
questionnaire (Molly and Penprase, 2010). Leaders
implementing the transactional style also made positive contributions, but
fewer than that of a transformational style (Molly and Penprase,
2010). In addition, the laissez-faire, exceptional-passive and
exceptional-active styles all negatively impacted the nursing environment
(Molly and Penprase, 2010). Corrigan et al (2002)
carried out a mental health study, consisting of 236 leaders who had
responsibility for 620 staff members. Leaders who noted themselves as high on
the transactional style, had staff outlining low transformational scores. In
comparison, leaders who noted high levels of inspirational and stimulatory
aspects were likely to have staff who felt that their style was transformative
(Corrigan et al, 2002). Lastly, staff members who stated that their leader has
a transformational style experienced less burnout, a better working environment
and support, adhering to conclusions by Malloy and Penprase
(2010). In a time of uncertainty, healthcare budget cuts, policy changes and
financial strain, transformational leadership is key (Cleary et al, 2011). It
encourages staff to treat patients with respect and dignity, promoting patient-centred care and upholding values (Cleary et al, 2011).
Many argue however, that there needs to be more evidence into whether
transformational leaderships enable better care, improved quality of life and
patient satisfaction (Holm and Severinsson, 2010).

NHS leadership review

The government
published findings in order to analyze leadership within the NHS (Department of
Health, 2015). It noted three main areas of concern: a lack of vision, poor
management and leadership and the need for clear pathways in regards to NHS
management careers (Department of Health, 2015). The key recommendations
include: refreshing the NHS graduate scheme, the transfer of NHS leadership
Academy to Health Education England as those responsible for training and
introducing a minimum term on some senior management contracts. In addition,
managers should be supported and have their knowledge updated regularly in
order to prevent ‘skill fade’ (Department of Health, 2015: 53). The report
concluded that, ‘the NHS as a whole, lacks a clear, consistent, view of what
‘good’ or ‘best’ leadership looks like’ (Department of Health, 2015: 20). The
recommendations focus upon training, management, support, performance
management and bureaucracy (Department of Health, 2015).


To conclude, effective
leadership is necessary in order to provide a high level of safe care. It leads
to patient-centered care, excellent communication skills and high quality care.
Leaders need to communication well, have emotional intelligence, distribute
work and implement a transformational style. Whereas poor leadership can lead
to death or severe harm, as took place in the independent investigation into
the Airedale NHS trust. Ineffective leadership was also a main aspect of why
the detrimental acts of Anne Grigg-Booth went undetected by managers (Nicolson
et al, 2011). To emphasise, leadership is a key area
of the NHS and so it is vitally important to ensure that behaviours,
communication skills, qualities, skills, leadership styles and strategies are
focused upon to improve (West et al, 2015). Without doing so, the lives of many
will be affected.






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