Psychiatric Note Reflection Questions
Complete Modules 1-3 of the American Psychiatric Nurses Association’s MAT: Medications for Addiction Treatment 8 Hour Waiver TrainingLinks to an external site..
Then submit a progress note and answer reflection questions based on the case presented in Module 3 of the MAT training. *Some information was not provided in the case. Complete as much information as possible.
Reflection questions:
What are your nursing experiences with persons with substance use disorder (SUD)?
The case scenario describes a lawyer who is using heroin. Prior to the training, were you aware that according to the World Health Organization (2020), drug use disorders are the most stigmatized conditions by health care providers? Did you think that a successful person could suffer from substance use disorder?
Did completing this training change how you will screen for SUD and treat clients who suffer from SUD? Why or why not?
Do you plan to complete the MAT training and become Suboxone-waivered? Why or why not?
Psychiatric Note Format
Demographic data: Do not include identifying information. Must be HIPAA compliant.
Chief complaint:
History of present illness:
Current working diagnoses:
Current psychiatric medications:
Non-psychiatric medications:
Allergies:
Review of Systems: As appropriate, listed by body systems in bullet form
Mental Status Exam:
Physical Exam: Physical exams should be appropriate for the patient and your clinical setting. For example: a telehealth follow up for MDD versus an inpatient psychiatric unit for acute psychosis will have different physical exams.
VS: If obtained
Results: If applicable and results obtained
PHQ9: HAM-A
Labs:
Impression: Narrative discussion of current status and symptoms, how the patient is tolerating the current treatment and any progress toward goals. Also discuss any change in diagnoses or changes to the plan and the reason why. Always discuss the safety evaluation and current safety plan.
Plan:
Medication orders
Psychotherapy orders to begin or continue
Safety orders
Non-pharmacologic orders – labs, psychoeducation, referrals
Follow up
Signature: Current credentials, PMHNP student
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