NRNP 6675 Week 2 Assignment 1 – Step-by-Step Guide
The first step before starting to write the NRNP 6675 Week 2 Assignment 1: Evaluation and Management (E/M), it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.
How to Research and Prepare for NRNP 6675 Week 2 Assignment 1
The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility.
Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.
How to Write the Introduction for NRNP 6675 Week 2 Assignment 1
The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.
How to Write the Body for NRNP 6675 Week 2 Assignment 1
The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.
How to Write the In-text Citations for NRNP 6675 Week 2 Assignment 1
In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:
The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.
How to Write the Conclusion for NRNP 6675 Week 2 Assignment 1
When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.
How to Format the Reference List for NRNP 6675 Week 2 Assignment 1
The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication.
Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:
References
Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456
Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.
An Example PNRNP 6675 Week 2 Assignment 1 Follows:
Pathways Mental Health
Psychiatric Patient Evaluation
| Instructions | 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 altogether 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.” | ||
| HPI | 25 yo Russian female evaluated for psychiatric health status, having been referred by her retiring practitioner for PTSD, ADHD, and Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg PO daily for PTSD, atomoxetine 80mg PO daily for ADHD. Today, the 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 frustration, loses things easily, makes mistakes, and has difficulty 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 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 19 after being raped by a stranger during a house burglary.Previous Psychiatric Hospitalizations: deniedPrevious Detox/Residential treatments: one for abuse of stimulants and cocaine in 2015Previous 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):SubstanceY/NFrequency/Last UseTobacco productsY½ETOHYlast drink 2 weeks ago, reports drinks 1-2 times monthly, one drink socially CannabisN CocaineYlast use 2015Prescription stimulantsYlast use 2015MethamphetamineN InhalantsN Sedative/sleeping pillsN HallucinogensN Street OpioidsN Prescription opioidsN Other: specify (spice, K2, bath salts, etc.)Yreports 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 a Russian orphanage. She has unknown siblings. She is single; has no children. Employed at a local tanning bed salonEducation: High School DiplomaDenied current legal issues. | ||
| Suicide / HOmicide Risk Assessment | RISK FACTORS FOR SUICIDE:· 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 PROTECTIVE FACTORS FOR SUICIDE:· 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 yo Russian female who looks her stated age. She is cooperative with the 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 a 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 a 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. Based on her current clinical presentation and her risk and protective factors, she is at low risk for self-harm. | ||
| Diagnostic Impression | [Student to provide DSM-5-TR and Updated ICD-10 coding]PTSD – 309.81 (DSM-5-TR), F43.10 (ICD-10)ADHD – 341.0X (DSM-5-TR), F90.X (ICD-10) | ||
| 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, 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 was obtained. Not to drive or operate dangerous machinery if feeling sedated. Not to stop the 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 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 the 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 the nearest ER or call 911 if they became actively suicidal and/or homicidal. 5) Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand the discussion and appears 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, reviewed PCP history and physical dated one week ago and include lab results Patient is amenable to this plan and agrees to follow the treatment regimen as discussed. | ||
Narrative Answers
Specific and relevant information is required to diagnose and code medical illnesses using documentation supporting DSM-5-TR correctly and updated ICD-10. All relevant information for doctors, insurers, and scientists can be extracted from this record of the patient’s condition. The following details, essential to accurate coding, should be included in the supporting documentation:
It is crucial to get a complete medical history from the patient. This covers the patient’s medical and mental health history and demographic details like gender, age, and race. Any preexisting diseases or comorbidities may affect the diagnosis and subsequent classification; therefore, it is vital to keep track of them (Heath, 2019). Next, getting specific about the patient’s chief complaint is essential. The patient’s subjective experiences, such as symptom onset, duration, and severity, must be recorded. Learning how the patient’s symptoms affect their daily lives and what may aggravate or alleviate them is essential.
A complete mental status evaluation must also be documented. The patient’s personality, appearance, conduct, mood, affect, speech, thought processes, and sensory abnormalities are all considered during this evaluation. In addition, the healthcare provider needs to write down their initial thoughts about a diagnosis and any examined possibilities. The best diagnosis can be made by applying the criteria in the DSM-5-TR after all other potential explanations for the symptoms have been eliminated (Burks et al., 2022).
The evaluation should also include a summary of the treatment plan and any implemented interventions. Medical, psychological, or counseling therapies fall under this. The clinician needs to track how the patient is doing, how their symptoms are changing, and any problems they have due to the treatment. Finally, all documentation must follow the DSM-5-TR and ICD-10 coding guidelines. The diagnosis and any recognized subtypes or severity levels should be reflected in the allocated codes. The codes should be backed up by evidence demonstrating why the services were medically necessary.
The following is the information that is missing:
Review of Systems
The review of systems includes recording signs and symptoms indicating anomalies in the body systems, such as the respiratory, digestive, circulatory, and neurological systems. A comprehensive record of this data helps to create a complete overall health status picture of the patients.
Physical Examination Findings
Physical examination findings include the patient’s vital signs, overall appearance, and pertinent health findings relating to the chief complaint.
Progress Notes
Progress notes help the healthcare providers to note any variations in the client’s health status, prompting quick interventions to maintain an optimal status of the patient. The notes are also essential for billing and coding the patient’s services.
How to improve documentation to support coding and billing for maximum reimbursement
It is essential for healthcare workers to explicitly state the chief complaint presented by the patients, their past health history, physical examination findings, and the results from diagnostic tests. The family, social and psychiatric history is also essential to be captured. The symptoms presented by the patient should be recorded using clear and succinct terminologies by noting their intensity and the influence on the activities of daily living of the patients (Bhagavath et al., 2021). The healthcare workers should also determine if the diagnoses they reach correlate with the DSM-5-TR guidelines.
PNRNP 6675 Week 2 Assignment 1 References
Bhagavath, B., Goodman, L., & Petrozza, J. (2021). Billing, coding, and practice management: a primer for today’s reproductive medicine professional. Fertility and Sterility, 115(1), 22–28. https://doi.org/10.1016/j.fertnstert.2020.11.023
Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 10, 205031212210990. https://doi.org/10.1177/20503121221099021
Heath, C. B. (2019). Coding, Billing, and Reimbursement for Procedures. 7–11. https://doi.org/10.1007/978-3-030-28884-6_2
Yates, T., Rotolo, P., & Bryce, Y. (2022). The Money Side: Billing, Coding, Reimbursement, Costs, and Marketing. Techniques in Vascular and Interventional Radiology, 100859. https://doi.org/10.1016/j.tvir.2022.100859
Having completed this evaluation and management task, let’s see how we will fair in the next task, which requires you to complete a focused soap note on anxiety, PTSD or OCD, based on a given case study. The assignment is due in week 3 of NRNP 6675.
Frequently Asked Questions (FAQs)
When approaching a 500-word essay, it’s essential to understand the nuances of this compact form of writing. These frequently asked questions will guide you through the process of crafting a concise and impactful essay.
How many pages is a 500-word essay typically?
A 500-word essay usually spans about one page if single-spaced or two pages when double-spaced, with standard margins and a 12-point font size.
Can you provide examples of a well-structured 500-word essay?
Certainly, to see the structure and flow of a well-written essay, you might want to take a look at a student’s writing guide that provides insights and examples.
Are there specific formatting guidelines for a 500-word essay?
Formatting guidelines typically involve using a legible font like Times New Roman or Arial, size 12, with double-spacing and one-inch margins on all sides. Check any specific requirements your instructor might have provided.
What are some effective strategies for writing a personal essay of 500 words?
For a personal essay, focus on a singular event or characteristic, ensuring your ideas are clear and you reflect on the significance of the subject matter. Use concise language and powerful imagery to maximize impact.
What topics are suitable for a concise 500-word essay?
Choose topics you can thoroughly address within the word limit, such as a personal anecdote, a critical analysis of a poem, or a focused argument on a singular point or issue.
How much time should you allocate to write a 500-word essay effectively?
Depending on your familiarity with the topic and writing proficiency, allocate anywhere from one to several hours for planning, drafting, and revising to ensure a well-presented essay.
