Assessment and Diagnosis Journey’s intake unit completes all initial assessment to assess client for different level of care and accurately assign them to the most appropriate unit. The different level of care ranged from intensive inpatient care unit to medication only. As a practicum student, I worked in the outpatient services unit. The assessment was completed via an online program with an intake staff and the client, usually a week or two before the first scheduled appointment with a clinician. Therefore, once a client is assigned to me, I have access to review their file. The assessment are usually completed in a brief model format, and as the clinician assigned to work with a client, I am expected to use the first two sessions of therapy …show more content…
Since being seen at Journey starting in 2011, Lucy has had the same diagnoses with the exception of her first time at Journey, where she was diagnosed with Adjustment Disorder with Mixed Anxiety and Depressed Mood. However, that diagnosis was dropped when she came back in 2012. She is currently prescribed Wellbutrin for mood, Gabapentin for anxious symptoms, Trazodone for mood and anxious symptoms, and Zoloft for obsessive-compulsive symptoms by her primarily care provide in a community clinic. Journey does not have additional assessment measures to assist in further diagnostic evaluation. Also, the clinician Lucy was working with is no longer an employee of the agency, which prevents opportunity to consult. Therefore, the diagnoses are based on my clinical assessment and my supervisor’s input. Based upon Lucy’s self-report, our interactions, and my on-going assessment, I have decided to maintain some of Lucy’s initial diagnoses with the addition of a V code. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM; 2013), Lucy was diagnosed with the following
Helen recurrent mood episodes and suicidal ideation needs to be addressed immediately. Her moods episodes
This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has
The intake process of patients is different from practice to practice, but the main purpose of the process is retrieve new and established patients information during check in at a providers office, a hospital, or clinic. By having an efficient intake process a efficient patient flow can be maintained.
Described the DSM-5 signs and symptoms you observed for Shelly, Polly, Brittany and Alisa. Be thorough and specific
It's a common misconception that attending an inpatient or outpatient rehab program will produce an immediately successful recovery from addiction. While it's true that traditional and alternative rehab programs can help their clients get sober and develop good strategies to combat their addiction, the reality is that 40% or more of recovering addicts suffer a relapse within a year after the completion of their program. The first several years are the most definitive in terms of creating a habit of sobriety, which is why so many professionals recommend post-treatment support, such as AA meetings. Springfield, IL, is home to several different AA chapters, and BetterAddictionCare can help find the best one for you.
The psychiatric clinical rotation at Clinch Mountain House was a very prodigious experience. This facility is unique because of the role it plays in the community; it serves to provide daily recreation for the members of the community who suffer from mental illnesses. This facility focuses on providing essential social skills to this community and accomplishes this goal by providing social interaction, a structured schedule, and daily assignments for each member.
On April 7th, 2016, a 36 year old male inpatient at Tattnall Optim Medical Center come to radiology department for a procedure that include two views of chest and five views of bilateral ribs. Human Immunodeficiency Virus (HIV) and decreased white blood cell (WBC) were included in the patient’s medical history. The patient also experiences a chest pain, cough, shortness of breath, and weakness. He mentions that he have a bilateral ribs pain. HIV infection is a disease that affect the body’s immune system by attacking and destroying T lymphocytes, making the affected person susceptible to numerous respiratory infection and malignant tumor (Crowley, 2007. p. 158).
We are writing to request a waiver for the Inpatient Rehabilitation Facility (IRF)- Patient Assessment Indicator (PAI) penalty for that attached list of claims. The IRF unit for Medical City Dallas opened on 6/1/2016 and received the finalized tie-in notice on 6/16/17. PAI information was submitted once tie-in was finalized; however, the claims received a 25% PAI penalty. Our MAC is Novitas.
The patient was in the same condition. The interim assessment was occurred before the treatment. Homecare performed was the same by stretching the hamstrings and partial sit ups. Massage was followed the same and homecare was changed to a squat position to encourage strengthening of the hamstrings.
What is a medical condition? A medical condition falls into three or more categories, the most common one is disease. For example, Multiple Sclerosis is a disease that you will always have once you are diagnosed with it. When you have a disease now, you go for treatment. But when there was no treatments for diseases they just let you die on a bed or during the aztecs they ripped your hearts outs. Then decorated the ancient temples with the human blood. Now with diseases as I said you can go get treatment like you can get prescriptions go to group therapy and have special doctors. For treatment for people who do not already have diseases you can get injections for your body, so you are allowing small dosages of the disease. So if you do get the disease later on your
When working for a medical office you should be ready to deal with the unexpected on a daily basis. The office should be prepared and equipped to handle any emergency’s plēmthat will arise. Emergency’s such as these should be handled promptly with no delay.
I believe I had a very positive overall experience observing Dr. Kiani in his private clinical setting in McAllen and at the Doctor’s Hospital at Renaissance and Rio Grande Regional Hospital. I do have quite a bit of shadowing experience; therefore, I was familiar with typical physician-patient interactions but of course the medical interview is centered differently in different specialties.
Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking
The demands of the current health care system provide a powerful reason for advanced clinical decision making. It is undeniably a responsible approach to providing best possible care to patients. Nurses are required to integrate evidence-based clinical decisions as they solve problems regarding patient care during the nursing process. Nursing knowledge, as well as patient values, expert opinions, and evidence on how best to care for the patient are incorporated during the nurse’s clinical decision making. There are a lot of decision making theories and models that are widely used in clinical setting. Therefore this paper will discuss how decision making is used in placement
Today, the medical field is one of the highest paying professional fields in the United States. The field, however, is not noted for its rewarding salaries, but for its importance all over the world. Medicine is one of the oldest professional fields. According to the Oxford Advanced Learner 's Dictionary, Medicine “is the science or practice of the diagnosis, treatment, and prevention of disease.” The field employs several people like, nurses, doctors, therapists and others. To be professionally employed in the medical field, one extensively needs at least 4 years of education and or training. Doctors, for instance, spend 4 years in college before being enrolled in a rigorous 4 year program in medical schools. Because of the delicate and intricate nature of the field, a wide range of tools and machinery are persistently used. The technology used today in medicine is dramatically different from what was used in ancient times. Using technology as a basis, the field of medicine has witnessed substantial advancements.