Florida International University Clinicals Psychiatric Management II Psychopharmacology management and behavioral issues

Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template

CLIENT WAS SEE IT ON NOVEMBER 15 2023

Download Graduate Comprehensive Psychiatric Evaluation Templateto:

Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

For the Comprehensive Psychiatric Evaluation Presentation Assignment:You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

Step 2:Each student will create a focused SOAP note video presentation in the next assignment. See Comprehensive Psychiatric Evaluation Presentation 3 for more details.

Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)

O =

Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam

A =

Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up

Psychiatric SOAP Note Rubric
Criteria
Chief Complaint
(Reason for
seeking health
care) – S
Demographics S
History of the
Present Illness
(HPI) – S
Allergies – S
Review of
Systems (ROS) S
Ratings
4 to >3.0 points
Exemplary
Includes a direct
quote from patient
about presenting
problem.
2 points
Exemplary
Begins with patient
initials, age, race,
ethnicity, and gender
(5 demographics).
5 to >3.0 points
Exemplary
Includes the
presenting problem
and the 8 dimensions
of the problem (OLD
CARTS – Onset,
Location, Duration,
Character,
Aggravating factors,
Relieving factors,
Timing, and Severity).
2 points
Exemplary
Includes NKA
(including = Drug,
Environmental, Food,
Herbal, and/or Latex
or if allergies are
present (reports for
each severity of
allergy AND
description of
allergy).
5 to >3.0 points
Exemplary
Includes a minimum
of 3 assessments for
each body system,
assesses at least 9
body systems
directed to chief
complaint, AND uses
the words “admits”
and “denies.”
Points
3 to >2.0 points
Distinguished
Includes a direct
quote from patient
and other unrelated
information.
1.5 points
Distinguished
Begins with 4 of the 5
patient demographics
(patient initials, age,
race, ethnicity, and
gender).
3 to >2.0 points
Distinguished
Includes the
presenting problem
and 6 of the 8
dimensions of the
problem (OLD CARTS
– Onset, Location,
Duration, Character,
Aggravating factors,
Relieving factors,
Timing, and Severity).
2 to >0.0 points
Developing
Includes information
but information is
NOT a direct quote.
0 points
Novice
Information is
completely
missing.
1 points
Developing
Begins with 3 or less
patient demographics
(patient initials, age,
race, ethnicity, and
gender).
2 to >1.0 points
Developing
Includes the
presenting problem
and 4 of the 8
dimensions of the
problem (OLD CARTS
– Onset, Location,
Duration, Character,
Aggravating factors,
Relieving factors,
Timing, and Severity).
0 points
Novice
Information is
completely
missing.
1.5 points
Distinguished
If allergies are
present, student does
not list each type of
drug, environmental
factor, herbal, food,
latex name and
include severity of
allergy OR description
of the allergy.
1 points
Developing
If allergies are
present, student only
lists the type of
allergy and omits the
name of the allergy.
3 to >2.0 points
Distinguished
Includes 3 or fewer
assessments for each
body system,
assesses 5-8 body
systems directed to
chief complaint, AND
uses the words
“admits” and
“denies.”
2 to >0.0 points
Developing
Includes 3 or fewer
assessments for each
body system, and
assesses less than 5
body systems
directed to chief
complaint, OR
student does not use
the words “admits”
and “denies.”
1 to >0 points
Novice
The presenting
problem is not
clearly stated
and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). 0 points Novice Information is completely missing. 4 points 2 points 5 points 2 points 0 points Novice Information is completely missing. 5 points Vital Signs - O Labs, Diagnostic Tests and Screening Tools O Medications-S Past Medical History-S Past Psychiatric History-S 2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). 3 points Exemplary During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. 3 points Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). 1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). 2 points Distinguished During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. 1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). 1 points Developing During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. 0 points Novice Information is completely missing. 2 points Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency). 0 points Novice Information is completely missing. 3 points Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. 4 to >3.0 points
Exemplary
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (including
2 points
Distinguished
Includes
(Major/Chronic,
Trauma,
Hospitalizations), for
each medical
diagnosis, either year
of diagnosis OR
whether the
diagnosis is active or
current.
3 to >2.0 points
Distinguished
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (omits
1 points
Developing
Includes a list of
some of the patient
reported psychiatric
and/or medical
medications and the
diagnosis for the
medication (omits the
dose, route,
frequency of the
medications).
1 points
Developing
Includes each medical
diagnosis but does
not include year of
diagnosis or whether
the diagnosis is active
or current.
2 to >0.0 points
Developing
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (including
0 points
Novice
The information is
completely
missing.
2
points
0 points
Novice
Information is
completely
missing.
3
points
3
points
0 points
Novice
Information is
completely
missing.
3
points
4
points
Family
Psychiatric
History-S
Social History-S
Mental Status
Exam-O
Primary
Diagnoses-A
addiction treatment),
and year of diagnosis.
addiction treatment),
and year of diagnosis.
4 to >3.0 points
Exemplary
Includes an
assessment of at least
6 family members
regarding, at a
minimum, genetic
disorders, mood
disorder, bipolar
disorder, and history
of suicidal attempts.
3 points
Exemplary
Distinguished
Includes all 11 of the
following: tobacco
use, drug use, alcohol
use, marital status,
employment status,
current and previous
occupation, sexual
orientation, sexually
active, contraceptive
use/pregnancy status,
and living situation.
15 to >12.0 points
Exemplary
Includes all 10
components of the
mental status exam
(appearance,
attitude/behavior,
mood, affect, speech,
thought process,
thought content/
perception, cognition,
insight and
judgement) with
detailed descriptions
for each area.
3 to >2.0 points
Distinguished
Includes an
assessment of at least
4 family members
regarding, at a
minimum, genetic
disorders, mood
disorder, bipolar
disorder, and history
of suicidal attempts.
2 points
Distinguished
Includes at least 8 of
the following:
tobacco use, drug
use, alcohol use,
marital status,
employment status,
current and previous
occupation, sexual
orientation, sexually
active, contraceptive
use/pregnancy status,
and living situation.
12 to >10.0 points
Distinguished
Includes all 8
components of the
mental status exam
(appearance,
attitude/behavior,
mood, affect, speech,
thought process,
thought content/
perception, cognition,
insight and
judgement) with
detailed descriptions
for each area.
11 to >6.0 points
Exemplary
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses addressed
at the visit (in
descending priority)
using the DSM-5-TR.
6 to >3.0 points
Distinguished
Includes a clear
outline of the
accurate diagnoses
addressed at the visit
but does not list the
diagnoses in
descending order of
priority using the
DSM-5-TR. The
addiction treatment),
and does not include
the year of diagnosis.
2 to >0.0 points
Developing
Includes an
assessment of at least
2 family members
regarding, at a
minimum, genetic
disorders, mood
disorder, bipolar
disorder, and history
of suicidal attempts.
1 points
Developing
Includes all 6 of the
following: tobacco
use, drug use, alcohol
use, marital status,
employment status,
current and previous
occupation, sexual
orientation, sexually
active, contraceptive
use/pregnancy status,
and living situation.
10 to >0.0 points
Developing
Includes >6
components of the
mental status exam
(appearance,
attitude/behavior,
mood, affect, speech,
thought process,
thought content/
perception, cognition,
insight and
judgement) with
some descriptions for
each area.
3 to >0.0 points
Developing
Includes an
inaccurate diagnosis
as the principal
diagnosis. The ICD-10
code is incorrect or
missing.
0 points
Novice
Information is
completely
missing.
4
points
0 points
Novice
Information is
completely
missing.
3
points
0 points
Novice
Includes 8.0 points
Exemplary
Includes a detailed
pharmacologic and
non pharmacological
treatment plan for
each of the diagnoses
listed under
“assessment”. The
plan includes ALL of
the following:
drug/vitamin/herbal
name, dose, route,
frequency, duration
and cost as well as
education related to
pharmacologic agent.
For nonpharmacological
treatment, includes:
treatment name,
frequency, duration.
If the diagnosis is a
chronic problem,
student includes
instructions on
currently prescribed
medications as
above. The plan is
supported by the
current US clinical
guidelines.
correct ICD-10 billing
code is used.
2 points
Distinguished
Includes 1 differential
diagnosis that can be
supported by the
subjective and
objective data
provided using the
DSM-5-TR. The
correct ICD-10 billing
code is used.
1 points
Developing
Includes at least 1
differential diagnosis
that is NOT supported
by the subjective and
objective data. The
ICD-10 code is
incorrect or missing.
0 points
Novice
Information is
completely
missing.
2 points
Distinguished
After the visit: orders
appropriate
diagnostic/lab testing
50% of the time OR
acknowledges “no
diagnostic testing or
screening tool
clinically required at
this time.”
1 points
Developing
After the visit, orders
appropriate
diagnostic testing less
than 50% of the time.
0 points
Novice
Information is
completely
missing.
8 to >6.0 points
Distinguished
Includes a detailed
pharmacologic and
non pharmacological
treatment plan for
each of the diagnoses
listed under
“assessment”. The
plan includes 4-7 of
the following:
drug/vitamin/herbal
name, dose, route,
frequency, duration
and cost as well as
education related to
pharmacologic agent.
For nonpharmacological
treatment, includes:
treatment name,
frequency, duration.
If the diagnosis is a
chronic problem,
student includes
instructions on
currently prescribed
medications as
above. The plan is
supported by the
current US clinical
guidelines.
6 to >0.0 points
Developing
Includes a detailed
pharmacologic and
non pharmacological
treatment plan for
each of the diagnoses
listed under
“assessment”. The
plan includes 4 of the
following:
drug/vitamin/herbal
name, dose, route,
frequency, duration
and cost as well as
education related to
pharmacologic agent.
Non-pharmacological
treatment NOT
included. If the
diagnosis is a chronic
problem, student
includes instructions
on currently
prescribed
medications as
above. The plan is
NOT supported by
the current US clinical
guidelines OR is
unsafe.
0 points
Novice
Information is
completely
missing.
3
points
3
points
10
points
Patient/Family
Education-P
Referral
APA Formatting
References
5 to >3.0 points
Exemplary
Includes at least 3
strategies to promote
and develop skills for
managing their illness
and at least 3 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
3 points
Exemplary
Provides a detailed
list of medical and
other
interdisciplinary
referrals or
documents NO
REFERRAL ADVISED
AT THIS TIME.
Includes a timeline
for follow up
appointments.
5 to >3.0 points
Exemplary
Effectively uses
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended referencing.
High level of precision
with APA 7th Edition
writing style.
5 to >3 points
Exemplary
The reference page
contains at least the
required current
scholarly academic
reference and text
reference. Follows
APA guidelines of
components: double
space, 12 pt. font,
abstract, level
headings, hanging
indent and in-text
citations.
3 to >2.0 points
Distinguished
Includes at least 2
strategies to promote
and develop skills for
managing their illness
and at least 2 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
2 points
Distinguished
Provides a medical or
other
interdisciplinary
referral or documents
NO REFERRAL
ADVISED AT THIS
TIME. Includes a
timeline for follow up
appointments.
2 to >0.0 points
Developing
Includes at least 1
strategies to promote
and develop skills for
managing their illness
and at least 1 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
1 points
Developing
Provides a medical or
other
interdisciplinary
referral. DOES NOT
include a timeline for
follow up
appointments.
0 points
Novice
Information is
completely
missing.
3 to >2.0 points
Distinguished
Effectively uses
literature and other
resources to inform
their work. Moderate
use of citations and
extended referencing.
Moderate level of
precision with APA
7th Edition writing
style.
3 to >2 points
Distinguished
References page
contains one current
scholarly academic
resource and text
reference. Follows
most APA guidelines
of components:
double space, 12 pt.
font, abstract, level
headings, hanging
indent, and in-text
citations.
2 to >0.0 points
Developing
Ineffectively uses
literature and other
resources to inform
their work. Moderate
use of citations and
extended referencing.
APA 7th Edition
writing style not
strictly adhered to.
0 points
Novice
APA style and
writing mechanics
not used.
2 to >0 points
Developing
References page
contains one current
or outdated scholarly
academic resource.
Many errors of APA
guidelines: double
space, 12 pt. font,
abstract, level
headings, hanging
indent, and in-text
citations.
0 points
Novice
References page
contains no current
scholarly academic
resources, only
internet webpages
or no reference
page. Lack of APA
guidelines for
references
provided or in-text
citations.
5
points
0 points
Novice
Information is
completely
missing.
3
points
5
points
5
points
Psychiatric SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________
Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Psychiatric History:
Date
Date
Hospital
Inpatient hospitalizations:
Diagnoses
Length of Stay
Hospital
Outpatient psychiatric treatment:
Diagnoses
Length of Stay
Rev. 10162021 LM
Date
Hospital
Detox/Inpatient substance treatment:
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________
_________________________________________
_________________________________________
________________________________
________________________________
________________________________
Current prescription medications:
_________________________________________
_________________________________________
_________________________________________
________________________________
________________________________
________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________
_________________________________________
________________________________
________________________________
Rev. 10162021 LM
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Rev. 10162021 LM
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,
trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Rev. 10162021 LM
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Rev. 10162021 LM
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Rev. 10162021 LM
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Rev. 10162021 LM
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Rev. 10162021 LM
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Rev. 10162021 LM
6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
PATIENT
FACILITY
DEMONI BROOKS
DOB
AGE
SEX
PRN
Brooksville
04/28/2013
10 yrs
Male
BD918281
T (813) 373-9531
F (813) 413-4330
12200 Cortez Blvd
Brooksville, FL 34613
Patient identifying details and demographics
FIRST NAME
MIDDLE NAME
LAST NAME
SSN
DEMONI
BROOKS
–
SEX
DATE OF BIRTH
DATE OF DEATH
PRN
Male
04/28/2013
BD918281
CONTACT BY
EMAIL
shayla@creativegro
wthinc.com
(813) 401-9010
(678) 000-0147
–
RACE
ETHNICITY
PREF. LANGUAGE
STATUS
Active patient
CONTACT INFORMATION
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP CODE
3247 Thorny Ridge
Drive
Holiday
FL
34691
HOME PHONE
MOBILE PHONE
OFFICE PHONE
OFFICE EXTENSION
FAMILY INFORMATION
NEXT OF KIN
RELATION TO PATIENT
PHONE
ADDRESS
–
PATIENT’S MOTHER’S MAIDEN
NAME
–
Sunshine – Cenpatico
Primary
Medicaid
Self
06/01/2023
–
INSURED ID NUMBER
GROUP NUMBER
EMPLOYER NAME
INSURANCE PAYMENT TYPE
PAYMENT TYPE
COPAY AMOUNT
STATUS
9523354329
Copay
Fixed
Active
Primary Insurance
–
DATE OF BIRTH
SEX
SOCIAL SECURITY NUMBER
PRIMARY PHONE NUMBER
SECONDARY PHONE NUMBER
–
Active insurance
PRIMARY PAYER
PAYER
PRIORITY
TYPE
RELATIONSHIP TO INSURED
START DATE
END DATE
Inactive insurance
Payment information
PAYMENT PREFERENCE
PATIENT’S RELATIONSHIP TO
GUARANTOR
GUARANTOR NAME
GUARANTOR ADDRESS
–
https://static.practicefusion.com/apps/ehr/index.html?_gl=1*1vh7mv4*_gcl_au*MTAwNjE3NTg3MC4xNjg3Nzg3MTc1#/PF/charts/patients/01f93edf-fa1c-48c6-85…
1/11
6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Diagnoses
Current
ACUITY
START
STOP
ACUITY
START
STOP
(F84.0) Autistic disorder
(F90.2) Attention-deficit hyperactivity disorder, combined type
(F43.23) Adjustment disorder with mixed anxiety and depressed
mood
(G47.00) Insomnia, unspecified
(Z62.29) Other upbringing away from parents
(F98.3) Pica of infancy and childhood
(R45.87) Impulsiveness
Historical
No historical diagnoses
Drug Allergies
Active
SEVERITY/REACTIONS
ONSET
SEVERITY/REACTIONS
ONSET
SEVERITY/REACTIONS
ONSET
Patient has no known drug allergies
Food Allergies
Active
No food allergies recorded
Environmental Allergies
Active
No environmental allergies recorded
https://static.practicefusion.com/apps/ehr/index.html?_gl=1*1vh7mv4*_gcl_au*MTAwNjE3NTg3MC4xNjg3Nzg3MTc1#/PF/charts/patients/01f93edf-fa1c-48c6-85…
2/11
6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Medications
Active
SIG
START/STOP
ASSOCIATED DX
Amphetamine-Dextroamphetamine
(Amphetamine-Dextroamphet ER) 10 MG
Oral Capsule Extended Release 24 Hour
Take 1 capsule (10 mg) by
mouth daily in the morning
(must be generic per
insurance carrier)
06/05/23 –
–
Provider comment: Does not require a prior auth- it is a covered medication by Andrea Fisher on 06/05/23 (encounter DOS)
EScript (verified): 06/07/23 Prescriber: Andrea Fisher SIG: Take 1 capsule (10 mg) by mouth daily in the morning (must be generic
per insurance carrier) Refills: 0 Quantity: 30
EScript (cancelled): 06/05/23 Prescriber: Andrea Fisher SIG: Take 1 capsule (10 mg) by mouth daily in the morning (must be
generic per insurance carrier) Refills: 0 Quantity: 30
Guanfacine HCl (ADHD) (Intuniv) 4 MG
Oral Tablet Extended Release 24 Hour
take 1 tablet by mouth daily in
the morning (8am) for focus
and concentration
–
–
EScript (verified): 05/23/23 Prescriber: Andrea Fisher SIG: take 1 tablet by mouth daily in the morning (8am) for focus and
concentration Refills: 1 Quantity: 31
Hydroxyzine HCl (hydrOXYzine HCl) 50 MG
Oral Tablet
take 1 tablet by mouth three
times daily in the morning at
8am, the afternoon at 12pm
and at bedtime at 7pm for
anxiety / aggression
05/23/23 –
–
EScript (verified): 05/23/23 Prescriber: Andrea Fisher SIG: take 1 tablet by mouth three times daily in the morning at 8am, the
afternoon at 12pm and at bedtime at 7pm for anxiety / aggression Refills: 1 Quantity: 93
Melatonin 5 MG Oral Tablet
take 3 tablets (15mg) by
mouth daily at bedtime at 7pm
for insomnia
06/05/23 –
–
EScript (verified): 06/05/23 Prescriber: Andrea Fisher SIG: take 3 tablets (15mg) by mouth daily at bedtime at 7pm for insomnia
Refills: 0 Quantity: 93
Quetiapine Fumarate (SEROquel) 100 MG
Oral Tablet
take 1 tablet (100mg) by
mouth daily at bedtime at 7pm
for mood/insomnia
–
–
EScript (verified): 05/23/23 Prescriber: Andrea Fisher SIG: take 1 tablet (100mg) by mouth daily at bedtime at 7pm for
mood/insomnia Refills: 1 Quantity: 31
Sertraline HCl 50 MG Oral Tablet
Take 1 and a half tablets (75
mg) by mouth daily in the
morning at 8am for
depression and anxiety
05/23/23 –
–
EScript (verified): 05/23/23 Prescriber: Andrea Fisher SIG: Take 1 and a half tablets (75 mg) by mouth daily in the morning at 8am
for depression and anxiety Refills: 1 Quantity: 47
Historical
SIG
START/STOP
ASSOCIATED DX
Amphetamine-Dextroamphetamine
(Adderall XR) 5 MG Oral Capsule Extended
Release 24 Hour
Take 1 capsule (5 mg) by
mouth daily in the morning
(must be brand name per
insurance). UNABLE TO
OBTAIN FROM PHARMACY
– 06/05/23
–
EScript (verified): 06/02/23 Prescriber: Andrea Fisher SIG: Take 1 capsule (5 mg) by mouth daily in the morning (must be brand
name per insurance) Refills: 0 Quantity: 30
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Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Amphetamine-Dextroamphetamine
(Amphetamine-Dextroamphet ER) 5 MG
Oral Capsule Extended Release 24 Hour
30
Take 1 capsule (5 mg) by
mouth daily in the morning
05/24/23 – 06/02/23
–
EScript (verified): 05/24/23 Prescriber: Andrea Fisher SIG: Take 1 capsule (5 mg) by mouth daily in the morning Refills: 0 Quantity:
Dexmethylphenidate HCl (Focalin XR) 5
MG Oral Capsule Extended Release 24
Hour
Take 1 capsule (5 mg) by
mouth daily in the morning
(not available at the client’s
pharmacy)
05/23/23 – 05/24/23
–
Encounter comment: Unavailable at pharmacy by Andrea Fisher
EScript (cancelled): 05/23/23 Prescriber: Andrea Fisher SIG: Take 1 capsule (5 mg) by mouth daily in the morning Refills: 0
Quantity: 21
Melatonin 10 MG Oral Tablet
take 1 tablet by mouth daily at
bedtime at 7pm for insomnia
(dose increased)
– 06/05/23
–
EScript (verified): 05/23/23 Prescriber: Andrea Fisher SIG: take 1 tablet by mouth daily at bedtime at 7pm for insomnia Refills: 1
Quantity: 31
Immunizations
DATE
VACCINE
SOURCE
LOT
NUMBER
EXPIRES
COMMENT
No immunizations recorded for this patient.
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Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Social history
TOBACCO USE
RECORDED
No tobacco use history available for this patient
ALCOHOL USE
RECORDED
No alcohol use history available for this patient
SOCIAL HISTORY (FREE-TEXT)
No social history (free-text) recorded for this patient
FINANCIAL RESOURCES
RECORDED
No financial resources recorded for this patient
EDUCATION
RECORDED
No education recorded for this patient
PHYSICAL ACTIVITY
RECORDED
No physical activity available for this patient
NUTRITION HISTORY
RECORDED
No nutrition history available for this patient
STRESS
RECORDED
No stress available for this patient
SOCIAL ISOLATION AND CONNECTION
RECORDED
No social isolation and connection available for this patient
EXPOSURE TO VIOLENCE
RECORDED
No exposure to violence history available for this patient
GENDER IDENTITY
No gender identity recorded for this patient
SEXUAL ORIENTATION
No sexual orientation recorded for this patient
Past medical history
No past medical history available for this patient.
Family health history
DIAGNOSIS
ONSET DATE
No Family health history recorded
FAMILY HEALTH HISTORY (FREE TEXT)
No family health history (free text) available for this patient.
Advance Directive
DIRECTIVE
RECORDED
No advance directives recorded for this patient.
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Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Active health concerns
DESCRIPTION
EFFECTIVE DATE
No active health concerns recorded
Inactive health concerns
DESCRIPTION
EFFECTIVE DATE
No inactive health concerns recorded
Active Goals
DESCRIPTION
EFFECTIVE DATE
No active goals recorded
Inactive Goals
DESCRIPTION
EFFECTIVE DATE
No inactive goals recorded
PATIENT
DEMONI BROOKS
DOB
AGE
SEX
PRN
04/28/2013
10 yrs
Male
BD918281
FACILITY
ENCOUNTER
T (813) 373-9531
F (813) 413-4330
106 W Windhorst Rd
Brandon, FL 33510
NOTE TYPE
SEEN BY
DATE
AGE AT DOS
Not signed
Brandon
Office Visit
SOAP Note
Andrea Fisher
06/26/2023
10 yrs
Chief complaint
(Appt time: 6/26/2023 2:00:00 PM) (Arrival time: 8:33 AM)
Vitals for this encounter
No vitals recorded
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
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6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
PATIENT
FACILITY
ENCOUNTER
T (813) 373-9531
F (813) 413-4330
106 W Windhorst Rd
Brandon, FL 33510
NOTE TYPE
SEEN BY
DATE
AGE AT DOS
Not signed
DEMONI BROOKS
DOB
AGE
SEX
PRN
04/28/2013
10 yrs
Male
BD918281
Brandon
Telemedicine Visit
SOAP Note
Andrea Fisher
05/23/2023
10 yrs
Chief complaint
Follow-up MM
(Appt time: 5/23/2023 1:00:00 PM) (Arrival time: 8:22 AM)
Vitals for this encounter
No vitals recorded
SUBJECTIVE
CHIEF COMPLAINT: psychopharmacology management
ARRIVES WITH: APD support manager Shayla and group home staff member Ms Amber
INFORMANT(S): Shayla and group home staff
***requires a 5339 for all medication adjustments***
HISTORY OF PRESENT ILLNESS: client presents via telehealth from his school with group home staff Ms Amber- client is reported to
have no Improvements from his previous visit- remains adherent with his medications, tolerative to the changes with no adverse
effects. He was provided the discontinuation on Concerta and an increase on Seroquel, Sertraline, and Melatonin with some
bettering sleeping habits but no other therapeutic benefits reported from the medication adjustments. He recently was under a CPS
investigation due to biting a peer, causing injury. The case was closed but client requires 1:1 observation when around other peers
due to his impulsive behaviors- the behaviors are occurring in the school setting as well as the group home. The teachers call the
group home regarding the increase in aggressive / assaultive behaviors and he is not able to ride the bus at this time- requires staff
to take him/pick him up from school. The client has difficulty with transitioning to tasks he does not want to to- has increased biting
behaviors during this time and will also spit at staff/peers/teachers.
Shayla reports the client has recently been approved for ABA services, 3 days a week, and such is scheduled to start in the next
couple of weeks. The client shows low frustration tolerance, poor problem solving skills and inflexibility in his thinking complicated
by his inability to communicate.
Reviewed the client’s current medication regime- due to the current behaviors of the client, medication adjustments are
recommended at this time for the potential betterment of his overall mood and mental health status.
Shayla is aware a 5339 will be provided and marked urgent to prevent any delay in treatment and the client will be scheduled in two
weeks to assess for indications improving behaviors are replacing current behaviors- she has no questions and will follow-up with
the client as scheduled.
Previous medications trialed:
Ritalin IR (increased hyperactivity / anger)
Clonidine (ineffective for sleep/mood/focus)
Concerta (ineffective)
PAST PSYCHIATRIC HISTORY
•O/P Psychiatrist/therapists: multiple throughout his lifetime since the age of 2
•Previous diagnosis: autism spectrum disorder, attention deficit hyperactivity disorder
•Previous admissions: denies, no history reported
•Previous suicide attempts: denies, no history reported
•Past Medication History/Compliance: reports adherence with all medications as provided by group home staff
INITIAL EVAL WITH THIS PROVIDER JAN 2023
Client presents to become re-established as an active client for ongoing psychopharmacology management- the client has been a
client with Brighter Heights of FL off and on since 2019 and chart review completed- the client is noted to have frequent changes of
environmental settings due to family, foster families, and multiple group home settings are unable to safely manage the care of the
client and the client has been placed in his current group home setting November 2022. The client has been in the foster care setting
since 2014, removed from his biological family due to neglect.
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6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
The client has a diagnosis of autism complicated by attention deficit disorder diagnosed at the age of 2- more recently it is
noted/reported the client to have uncontrolled habits of ingesting non-food items, occurs daily, and has required medical
intervention, including hospitalization due to gastrointestinal blockage- it is reported the client has had an examination by the
pediatrician- discussed lab work due to reported severity of PICA behaviors and there has been no lab work forwarded to the current
group home setting and no ordered blood work pending- Shayla is aware lab work will be ordered at this time to rule out any
malnutrition/iron/zinc deficiency, which is a leading factor to the cause of the described behaviors.
The client is non-verbal, alert and sits quietly throughout the assessment.
It is reported the client’s behaviors have an extensive range- he is calm/quiet and can quickly “snap” and be aggressive towards
peers/staff/teachers, without any identifiable triggers. He bites, spits, kicks, slaps, and scratches and is difficult to de-escalate once
the behaviors have started. The client also has self-harming behaviors such as hitting himself in the face and head banging on either
the walls/floors – he has had ABA in the past but requires a new updated evaluation along with ordering recommendation to have
services restarted in the current group home setting- Shayla is aware such will be completed and reviewed by the medical director
for signature.
The client is reported to be “sleeping awful” – states he is going to sleep “fine” but will only sleep for 2-3 hours and will be up
throughout the remainder of the night- the client is hard to be redirected back to sleep due to his tantrums and fits and at times will
wake the other peers in the home.
The client requires direct assistance with most of his ADLs and is currently attempting to learn use of a “speech board” for
communication -he would benefit from PT/OT/ST evaluation for treatment recommendations- Shayla is aware a referral for such
services will be provided at this time.
Reviewed the client’s current medication regime and discussed options for management of the client’s level of aggression and mood
instability- the client’s current behaviors indicate the need for a therapeutic increase in the dose on clonidine to aid in sleep
maintenance along with improving impulsivity and aggression along with the initiation of a low dose of sertraline to better aid the
client’s probable underlying levels of anxiety/depression with the anticipated benefit of improving the client’s level of frustration
tolerance during times of perceived stress to the client while maintaining his current dose/frequency of Guanfacine and melatonin.
A 5339 is completed and forwarded to support staff for changes in the medications and needed lab work/support therapy services.
Shayla has no questions at this time and verbalizes understanding via teach back method of all educational content provided at this
visit.
Client will be scheduled for a follow-up in 4 weeks, or sooner if necessary, for ongoing monitoring and further medication
adjustments if indicated.
SUBSTANCE ABUSE HISTORY
•Tobacco: denies, no history reported
•ETOH: denies, no history reported
•Illicit Drugs: denies, no history reported
Marijuana Use/Medical Card: denies, no history reported
Rehab Programs: denies, no history reported
FAMILY PSYCHIATRIC HISTORY
Biological mother: drug abuse; ADHD; bipolar disorder
Biological father: drug abuse
LENGTH OF GESTATION: full term pregnancy
BIRTH WEIGHT: unknown
NEONATAL COMPLICATIONS: no NICU requirement at time of birth: Patient has delayed developmental milestones including
crawling, walking, language acquisition and comprehension. Behavioral issues were first noticed at age 2.
PAST MEDICAL HISTORY: PICA
PAST SURGICAL HISTORY: no prior surgical history reported in his file
CURRENT NON-PSYCH MEDICATIONS: no medical medications reported in use at this time
ALLERGIES: no known allergies reported
SOCIAL HISTORY
•Living Situation: group home setting with peers
•Marital History: single
•Children: n/a
•Occupation: n/a
•Education: client is in the 4th grade – client has an IEP with specialized program for diagnosis
•Parents: no contact with biological parents since 2020
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Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
•Siblings: uncertain
•Sexual Orientation: undisclosed
•History of Trauma/Abuse, all types: removed from biological mother 2019 due to neglect and placed with paternal grandmother as
guardian and his biological father, removed from that home in 2020 due to “safety” of the client
•Legal Issues past and present: denies, no history reported
Access to weapons: denies
Safety concerns at home: denies, reports stable and supportive environment
DCF Involvement: client is in the foster program and requires a 5339 form for all medication adjustments
05-23-2023
PSYCHIATRIC REVIEW OF SYSTEMS
Depression: (Rate on scale of 0-10, 0= no problem, 10=severe problem): client is non-verbal
Anxiety: (Rate on scale of 0-10, 0= no problem, 10=severe problem): client is non-verbal
Anger: (Rate on scale of 0-10, 0= no problem, 10=severe problem): client is non-verbal
Sleep patterns: reports great improvements in the client’s sleeping routine- sleeping 7-8 hours a night and easily redirected back to
bed if he awakens during the night
Suicidal: no passive/active suicidal ideations, plan, or intent noted/reported
Flag symptoms of suicide present: none noted this visit
Self-harming behaviors: client is reported to head bang, hit himself in the face when he is extremely agitated, reported behaviors
occur multiple times throughout the week both in the group home setting and school setting
Homicidal: denies, no history reported
Difficulty concentrating: daily
Appetite/Unintentional weight loss/gain: no changes reported in baseline appetite- eating 3 meals daily with snacks : no weight
fluctuations reported
Body image: fair
School performance: poor : reported the client continues with struggling maintaining his assignments in the classroom and requires
1:1 assistance throughout the school day- has no positive peer relationships and can be physically aggressive with peers and
teaching staff without any identifiable trigger
Hallucinations: Denies auditory/visual/tactile hallucinations.
Paranoia: denies, no recent history reported
Delusions: denies, no recent history reported – No evidence of delusions including paranoia, grandeur, jealousy, erotomanic,
somatic, or ideas of reference.
Anhedonia (loss of pleasure in activities): denies, no history reported
Lack of energy: denies, no history reported
Episodes of mania: Denies history of or current symptoms of mania including grandiosity, hyposomnia, hyper verbal speech, flight of
ideas, racing thoughts, distractibility, risky behaviors, increased psychomotor activity, goal directed behavior, and hyper sexuality.
Oppositional behavior: he continues with difficulty following redirection from authority figures, finds it difficult to transition from
tasks he enjoys to different tasks, has history of physical aggression and self-harming behaviors when he is directed to do things he
does not want to do or does not get what he wants at the time he wants it
Ask about unusual movements (piano fingers/tapping feet/chewing cheeks): denies, no history reported
OBJECTIVE
Mental Status Exam:
General Appearance: [] Well-groomed [xx ] Casual [ ] Disheveled [ ] Healthy [ ] Sickly [ ] Emaciated [ ] Obese [ xx] Appropriate for
season/setting
Hygiene: [ ] Poor [xx ] Adequate [ ] Good
Psychomotor Activity: [] WNL [ ] Slow [ ] Agitated [xx ] Restless [ xx] Fidgety [ ] Tremors [ ] Tics [ ] Catatonic
Speech: [] WNL [ ] Slow [ ] Hesitant [ ] Slurred [ ] Stuttering [ ] Mumbling [ ] Soft [ ] Loud [ xx] Mute (client is non-verbal) [ ] Rambling [ ]
Pressured [ ] Hyperverbal [ ] Aphasic
Mood: [ xx] Euthymic [ ] Neutral [ ] Depressed [ ] Anxious [ ] Dysphoric [ ] Irritable [ ] Hostile [ ] Angry [ ] Agitated [ ] Elated [ ] Euphoric
Affect: [xx ] Appropriate (for diagnosis) [ ] Inappropriate [ ] Constricted [ ] Flat [ ] Expansive
Illusions/Hallucinations: [xx ] None [ ] Auditory [ ] Visual [ ] Tactile [ ] Olfactory
Thought Content: [xx ] Reality based [ ] Preoccupied [ ] Obsessions [ ] Delusions [ ] Paranoia [ ] Tangential [ ] Circumstantial
Attention: [xx ] Alert [ ] Attentive [ xx] Distracted [ ] Lethargic [ ] Sedated
Concentration: [ ] Good [ ] Fair [ ] Poor [xx ] Variable
Orientation: [xx] Person [ ] Place [ ] Time [ ] Situation
Memory: [ ] Intact [xx ] Impaired: [ ] Immediate [ ] Recent [ ] Recent Past [ ] Remote
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Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Judgment: [ ] Good [ ] Fair [ ] Poor [xx ] Impaired
Insight: [ ] Good [ ] Fair [ ] Poor [xx ] Impaired
Impulse Control: [ ] Good [ ] Fair [ ] Poor [xx ] Impaired
ASSESSMENT
Axis 1: autism spectrum disorder; attention deficit hyperactivity disorder, combined type; adjustment disorder with mixed emotional
response; insomnia
Axis 2:
Axis 3: PICA
Axis 4: other upbringing away from biological parents; emotional lability; impulsivity; irritability and anger
Axis 5:
Demoni presents with behaviors consistent with placement on the autism spectrum complicated by a probable mood disorder and
Shayla is requesting medication adjustments for the potential betterment of the client’s overall mood and mental health statusRecommended Treatment:
Initiate Focalin XR for impulsivity / attention / focus amelioration
Increase dose on Sertraline for anxiety / depression amelioration
Increase frequency on Hydroxyzine hCl to three times a day for anxiety/impulsivity amelioration
Maintain the current dose/frequency on Guanfacine/Seroquel/Melatonin – provide refills if indicated
The client’s APD manager is agreeable to the treatment recommendations as outlined and verbalized understanding via teach back
method. The client’s APD manager was given ample time for any questions or concerns regarding assessment and
recommendations.
This provider has discussed the administration of psychotropic medications with this client’s APD manager which includes the
purpose of these medications, doses and frequency, the benefits that may be expected, the discomforts associated with the
medication, appropriate alternatives, and the consideration of how symptoms may or may not progress if the medication is
accepted or declined.
The client’s APD manager has agreed to contact emergency services for symptoms not controlled by current medication, or
worsening symptoms, or any worrisome thoughts. The client’s APD manager verbalizes a clear, concise, and complete understanding
of the teachings and has no questions/concerns at this time.
The client’s APD manager has been offered the crisis line contact number (813) 964-1964
The client’s APD manager has been offered the community resource number for NAMI (813) 273-8104
The client’s APD manager has been offered the suicide prevention lifeline contact number (800) 273- TALK (8255)
Diagnoses attached to this encounter:
(F84.0) Autistic disorder
(F90.2) Attention-deficit hyperactivity disorder, combined type
(F43.23) Adjustment disorder with mixed anxiety and depressed mood
(G47.00) Insomnia, unspecified
(Z62.29) Other upbringing away from parents
(F98.3) Pica of infancy and childhood
PLAN
Continue supportive therapy and psychoeducation.
Recommended multi-modal compliance for optimal outcomes.
Discussed medication options with rationales including potential risks, benefits, side effects, interactions and dosage schedules of
medications and patient’s APD manager verbalized understanding.
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6/26/23, 11:30 AM
Patient chart – Patient: DEMONI BROOKS DOB: 04/28/2013 PRN: BD918281
Instructed on the potential adverse effects of alcohol/illicit drugs and advised against use and misuse of medications.
Smoking cessation discussed with patient [ ] Yes [ xx ] No
Patient’s APD manager was educated on available resources to utilize in case of psychiatric emergency, including presenting to the
ER or calling 911.
Labs/Diagnostics: [xx] None [ ] Drug Panel Test [ ] Depakote level [ ] Lithium level [ ] GeneSight [ ] EKG [ ] CBC [ ] BMP [ ] Thyroid
Function [ ] Other:
Screening Tests performed at this visit: n/a
Referral to specialist: n/a
-ABA referral provided Jan 2023 (still pending assessment as of March 2023) – SCHEDULED to start ABA services in 2 weeks (provided
3 x week)
-OT, PT, and ST referral provided Jan 2023
Take all medications as prescribed.
Medications remains appropriate and clinically indicated at this time
The client’s APD support manager is aware of HIPPA and privacy / confidentiality regulations
—Pg 3 and 4 of 5339 reviewed and completed with support staff who will review completed packet and forward to necessary parties
Follow up/plan: 2 weeks: assess tolerance for medications and overall effects on mental health status, plan to provide treatment
recommendations based on persistent symptoms; assess for suicidal ideations and for self-harming behaviors and provide
treatment recommendations accordingly ; plan to increase Focalin XR to 10mg if tolerance reported
Medication as detailed below:
-CONTINUE Seroquel 100mg take 1 tablet by mouth daily at bedtime at 7pm for mood/insomnia
-INCREASE Hydroxyzine hCl 25mg take 1 tablet by mouth three times a day at 8am, noon, and 7pm for anxiety/impulsivity
(therapeutic frequency increase from noon dosing)
-CONTINUE Melatonin 10mg take 1 tablet by mouth daily at bedtime at 7pm for insomnia
-INCREASE Sertraline 50mg take 1 and 1/2 tablet (75mg) by mouth daily in the morning at 8am for depression and anxiety
(therapeutic dose increase from 50mg)
-CONTINUE Guanfacine 4mg take 1 tablet by mouth daily in the morning at 8am for focus and concentration
-START Focalin XR 5mg take 1 capsule by mouth daily in the morning at 8am for focus, concentration, and impulsivity
Andrea L Fisher, PMHNP-BC
NPI# 1831781392
Supervising Physician: Hany Botros-Makhail MD
DEA# BB9685136 NPI# 1013014737
Quality of care
Was diagnosis reconciliation completed?
Yes, reconciliation performed
Was medication allergy reconciliation completed?
Yes, reconciliation performed
Was medication reconciliation completed?
Yes, reconciliation performed
Documentation of current medications
Screenings/ Interventions/ Assessments
No active screening/interventions/assessments recorded.
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