Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SO

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

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NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the Assessment section, provide:

· Results of the mental status examination, presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .

· Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2022 Walden University Page 1 of 3

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Chief Complaint inpatient psychiatric evaluation for depression with suicidal ideation Legal Status: voluntary and capacitated History of Present Illness 25 year old male with past psychiatric history of unspecified mood disorder (with history of mania) and psychosis (both likely medication/substance-induced) who presented voluntarily secondary to depression and active SI and reporting attempted OD with Wellbutrin 2 days ago. He did not seek medical/psychiatric attention until presenting to crisis because he "did not have the strength." He endorsed significant depressed mood, insomnia, anhedonia, hopelessness, helplessness, decreased energy, decreased concentration, decreased appetite, and suicidal ideation. He endorsed previous suicide attempts via OD. There was no evidence of mania/hypomania or psychosis. He was subsequently admitted to MDU for psychiatric stabilization and management. The patient was seen this morning, discussed with the ancillary staff, and the chart was reviewed. Upon interview today, the patient is lying in bed, appearing sleepy, in no acute distress, appearing dysphoric, slightly irritable, and with restricted affect. He says that he attempted to overdose on bottle of Wellbutrin (cannot quantify how many pills) 2 days prior to admission because he was just released from jail about 2-3 weeks ago, has been homeless since, and "couldn't live like that anymore." He says he has been feeling significantly and severely overwhelmed by this. He says during the time between being released from jail and presentation to hospital that he was homeless, he was having significantly depressed mood, anhedonia, insomnia, decreased appetite, decreased energy, decreased concentration, worthlessness, hopelessness, helplessness, and active suicidal ideation. He endorses about 3-4 previous suicide attempts via OD, but cannot recall exactly when last one was, however says that it was about 2-3 years ago. He says that since admission yesterday, he has been having good appetite, sleeping well but says "maybe a little too much," and feels safe here in the hospital. He says he does still feel "depressed." He also endorses consistent and current everyday use of cocaine, methamphetamines, and marijuana. DAU on admission positive for cannabis and cocaine. On chart review, the majority of psychiatric admission were in the context of substance use as evidenced by positive DAUs at the time of those admissions. He says that he desires inpatient rehabilitation. He relates that prior to being in jail for about a week, he was living with some family he has that live in Miami, however he will not be able to return there upon discharge as "they don't want me back." He does not endorse current SI/HI, AVH, paranoia, or symptoms of mania/hypomania. He reports inconsistent medication compliance with his current psychotropic medication regimen of Wellbutrin XR 300 mg daily and Abilify 15 mg daily. He has no somatic complaints. Of note, Beck's Depression Inventory on admission with score of 43. Target Symptoms: Quality: depression with suicidal ideation Duration: weeks Severity: severe, interfering with ability to care for self, interfering with daily functioning, interfering with safety of self or others Context: substance abuse, homelessness, just recently released from jail, questionable medication adherence Modifying factors: therapeutic milieu, rest, no access to substances Associated S/S: depressed mood, insomnia, anhedonia, worthlessness, hopelessness, helplessness, decreased energy, decreased concentration, decreased appetite Review of Systems: General: does not endorse fevers or weight change HEENT: does not endorse sore throat or congestion Cardiovascular: does not endorse chest pain or palpitations Respiratory: does not endorse cough or wheezing Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits Genitourinary: does not endorse dysuria or change in bladder habits Neurological: does not endorse dizziness or numbness MSK: does not endorse muscle or joint pain Past Psychiatric History:   First psychiatric visit at age 15 Previous psychiatric diagnosis: depression, psychosis, bipolar disorder, unspecified mood disorder, multiple substance use disorder Previous psychiatric hospitalizations: multiple, most recent 1/20/20-1/27/20 in ABC 1 Previous ECT: none Current outpatient psychiatrist: none Last visit to outpatient psychiatrist: years Past psychiatric medications: sertraline, risperidone, Ativan, Wellbutrin, Abilify, Remeron, Vistaril, trazodone Current psychiatric medications: Wellbutrin XL 300 mg daily and Abilify 15 mg daily Suicide history: 3 attempts by medication overdose, most recent 2020 (prior to one on current presentation)   Substance Use History:     Tobacco: does not endorse Alcohol: does not endorse Cannabis: endorses current and consistent use Cocaine: endorses current and consistent use Methamphetamines: endorses current and consistent use Opioids: does not endorse Benzodiazepines: does not endorse Amphetamines: does not endorse Hallucinogens: does not endorse Past Medical History:     does not endorse    Allergies: penicillin; cephalosporins Past Trauma History: Head trauma (TBI): does not endorse Seizure history: does not endorse Loss of consciousness: does not endorse Blackouts (substance related): does not endorse Family History: Mental illness: depression, OCD in father Suicide attempts/Completion: completed by grandmother (jumped off bridge), aunt attempted OD Substance abuse: does not endorse Social History: Born in Cuba and raised in by parents History of emotional, sexual, and/or physical abuse: does not endorse Education: 10th grade Employment status: unemployed If unemployed, makes ends meet by: unknown Living Situation: homeless Legal History: just released from jail ~2 weeks ago Support system: poor Physical Exam Vitals & Measurements T: 36.9 °C (Oral) TMIN: 36.7 °C (Oral) TMAX: 36.9 °C (Oral) HR: 53 RR: 18 BP: 109/60 SpO2: 99% Mental Status Examination Appearance: adequate grooming and hygiene, appears older than stated age Behavior: calm and superficially cooperative with interview, sleepy appearing, slightly irritable Eye Contact: poor Motor Activity: no PMA/PMR/AIMs noted Speech: normal rate, soft, low volume, with long latency Mood: "depressed" Affect: dysphoric / slightly irritable, constricted, congruent, reactive Thought Process: concrete Thought Content: slightly impoverished – Delusions: no delusions elicited – Perceptual Disturbances: does not endorse perceptual disturbances, not overtly RTIS Suicidal Ideation/Thought/Intent/Plan: does not endorse Homicidal Ideation/Thought/Intent/Plan: does not endorse Cognition – Attention/Concentration: fair/fair to interview – Orientation: awake, alert, oriented to person, location, date, situation Insight/Judgment: poor/poor Laboratory Test Results Urinalysis 06/29/2022 10:51 AM Urine Bacteria: 0 Urine Bilirubin: Neg mg/dL Urine Blood: Neg mg/dL UA Clarity: Clear Urine Color: Yellow Urine Glucose: Negative mg/dL Urine Ketones: Neg mg/dL Urine Leukocyte Esterase: Neg Urine Nitrite: Neg Urine pH: 6.0 — Normal range between ( 4.6 and 8.0 ) Urine RBC: 1 /HPF — Normal range between ( 0 and 3 ) Urine Urobilinogen: Negative mg/dL Urine Specific Gravity: 1.028 — Normal range between ( 1.001 and 1.035 ) Urine Protein: 30 Urine WBC: <1 /HPF — Normal range between ( 0 and 3 ) Mucous: Trace Urine Microscopic: Indicated Hematology 06/29/2022 10:48 AM Absolute Lymphocyte: 1.3 x10(3)/mcL — Normal range between ( 1.1 and 2.7 ) Absolute Neutrophil: 2.7 x10(3)/mcL — Normal range between ( 2.0 and 6.0 ) Basophil (%): 0.4 % — Normal range between ( 0.0 and 1.2 ) Eosinophil (%): 4.1 % — Normal range between ( 0.0 and 5.0 ) Hematocrit: 41.1 % — Normal range between ( 39.0 and 47.1 ) Hemoglobin: 14.2 g/dL — Normal range between ( 13.3 and 16.3 ) Lymphocyte (%): 27.6 % — Normal range between ( 16.0 and 43.0 ) MCH: 29.8 pg — Normal range between ( 27.1 and 33.1 ) MCHC: 34.5 g/dL — Normal range between ( 32.2 and 36.5 ) MCV: 86.3 fL — Normal range between ( 79.9 and 95.0 ) Monocyte (%): 10.7 % — Normal range between ( 6.0 and 12.0 ) Neutrophil (%): 57.0 % — Normal range between ( 36.0 and 70.0 ) Platelet Count: 183 x10(3)/mcL — Normal range between ( 140 and 400 ) RBC Count: 4.76 x10(6)/mcL — Normal range between ( 4.20 and 5.60 ) RDW-CV: 12.5 % — Normal range between ( 11.0 and 15.0 ) WBC Count: 4.7 x10(3)/mcL — Normal range between ( 4.0 and 10.5 ) MPV: 10.7 fL — Normal range between ( 9.4 and 16.4 ) Immature Granulocyte (%): 0.2 % — Normal range between ( 0.0 and 1.0 ) NRBC%: 0.0 /100WBC NRBC(Abs): 0.00 x10(3)/mcL Absolute Monocyte: 0.5 x10(3)/mcL — Normal range between ( 0.3 and 0.9 ) Absolute Eosinophil: 0.19 x10(3)/mcL — Normal range between ( 0.10 and 0.50 ) Absolute Basophil: 0.02 x10(3)/mcL — Normal range between ( 0.01 and 0.20 ) Absolute Immature Granulocyte: 0.01 x10(3)/mcL — Normal range between ( 0.00 and 0.10 ) Slide Review: Not Indicated General Chemistry 06/29/2022 10:48 AM Anion Gap: 6 — Normal range between ( 6 and 22 ) Albumin Level: 4.3 g/dL — Normal range between ( 3.9 and 5.0 ) Alkaline Phosphatase: 34 unit/L — Normal range between ( 38 and 126 ) ALT (SGPT): 23 unit/L — Normal range between ( 21 and 72 ) AST (SGOT): 27 unit/L — Normal range between ( 15 and 46 ) Vitamin B12: 811 pg/mL — Normal range between ( 232 and 1245 ) Blood Urea Nitrogen: 12 mg/dL — Normal range between ( 9 and 20 ) Calcium Level: 9.1 mg/dL — Normal range between ( 8.4 and 10.2 ) Cholesterol: 155 mg/dL — Normal range between ( 150 and 200 ) Chloride: 106 mmol/L — Normal range between ( 98 and 107 ) Calculated LDL: 64 mg/dL — Normal range between ( 65 and 160 ) Total CO2 Content: 30 mmol/L — Normal range between ( 22 and 30 ) CPK: 94 unit/L — Normal range between ( 57 and 374 ) Creatinine: 1.10 mg/dL — Normal range between ( 0.66 and 1.25 ) Folate: 8.7 ng/mL — Normal range between ( 7.3 and 26.1 ) GGTP: 17 unit/L — Normal range between ( 15 and 73 ) Glucose: 63 mg/dL — Normal range between ( 74 and 106 ) Glycohemoglobin: 5.0 % A1C — Normal range between ( 0.0 and 6.0 ) HDL: 48 mg/dL — Normal range between ( 40 and 60 ) Potassium: 4.8 mmol/L — Normal range between ( 3.6 and 5.0 ) Magnesium Level: 2.0 mg/dL — Normal range between ( 1.7 and 2.2 ) Sodium: 142 mmol/L — Normal range between ( 137 and 145 ) Osmolality Calculated: 281 mOsm/kg — Normal range between ( 275 and 295 ) Phosphorous: 3.3 mg/dL — Normal range between ( 2.5 and 4.5 ) Total Bilirubin: 0.5 mg/dL — Normal range between ( 0.2 and 1.3 ) Total Protein: 6.7 g/dL — Normal range between ( 6.3 and 8.2 ) Triglyceride: 217 mg/dL — Normal range between ( 40 and 160 ) eGFR (Non African-American): 93 eGFR (African-American): 108 Therapeutic Drug/Tox 06/29/2022 10:51 AM Amphetamine Class: Not Detected Benzodiazepine Class: Not Detected Cannabinoid: Presumptive Positive Cocaine & Metabolites: Presumptive Positive Opiate Class: Not Detected U Phencyclidine: Not Detected U Barbiturate Class: Not Detected U Methadone: Not Detected U Oxycodone: Not Detected 06/29/2022 10:48 AM Valproic Acid Level: <10 mg/L — Normal range between ( 50 and 100 ) Lithium Level: <0.20 mmol/L — Normal range between ( 0.50 and 1.20 ) Ethanol Level: <10 mg/dL — Normal range between ( 0 and 9 ) Endocrinology/Tumor Markers 06/29/2022 10:48 AM TSH: 1.640 mcIU/mL — Normal range between ( 0.270 and 4.200 ) Infectious Disease Testing 06/29/2022 10:48 AM Syphilis IgG IgM: Non-Reactive 06/29/2022 9:30 AM SARS CoV 2 RNA, RT PCR: Negative Assessment/Plan Unspecified depressive disorder (F32.9) r/o major depressive disorder r/o bipolar disorder r/o substance/medication-induced depressive disorder Stimulant (cocaine) use disorder, severe (F14.20) Stimulant (methamphetamine) use disorder. severe (F15.20) Cannabis use disorder, severe (F12.20) Patient has acute psychiatric symptoms and is in need of treatment and stabilization. Psychiatric symptoms intolerable to patient and/or society and at risk of re-hospitalization. Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment. In regards to patient's psychiatric symptoms, his suicidality/depressive symptoms prior to presentation are likely related to substance use and/or recent homelessness rather than primary depressive/mood disorder, especially given admission DAU positive for cannabis and cocaine, patient report of consistent/daily use of multiple substances, and history of positive DAUs during the majority of previous psychiatric admission. Therefore, the diagnosis of substance/medication depressive disorder is currently favored. Patient's current symptomatology has improved since admission and any residual symptomatology is likely a consequence of withdrawal from stimulants, and thus psychotropic medications are not currently indicated and/or needed. Will continue to monitor closely, revise differential/working diagnoses as needed, and treat as needed/indicated. Plan 1. Patient is voluntary and capacitated. 2. Medications: – no psychotropics indicated at this time as detailed above – refer to medication tab for rest of pharmacotherapy 3. Tobacco Cessation: N/A 4. Labs/Imaging: EKG pending for intermittent low BP and HR 5. Consults: none 6. Court Date: none 7. Social work evaluation for disposition and follow-up. 8. Patient was educated about reasons for prescribing the above medications, expected benefits and likelihood of clinical improvement, as well as potential side effects and relevant risks; treatment alternatives and side effects of the alternatives expected course without treatment and results of not receiving care. Patient was educated on how to take the medications. 9. Coordination of care provided with: nursing staff, treatment team: SW, CM, residents, MHTs, and physicians 10. Psycho education and support was provided. Medications, treatment plan and safety measures were discussed. Treatment team will continue to monitor adherence and follow response to treatment

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