NR 509 MENTAL HEALTH DOCUMENTATION

NR 509 MENTAL HEALTH DOCUMENTATION. Click to advance to main content. • • My Courses • My Results • Mental Health Results | CompletedAdvanced Health Ass essment Return to Assignment Your Results Turn In Lab Pass • Overview • Transcript • Subjective Data Collection • Objective Data Collection • Education & Empathy • Documentation • Lifespan • Review Questions • • Self­Reflection Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Subjective Ms.Tina Jones is a 28 year old African American presented to the clinic with the complaint of difficulty in sleeping for three and a half weeks.She reported HPI: Ms. Jones presents to the clinic complaining difficulty sleeping which she notes to have started month ago. She states that her sleep is “shallow an not restful”. She complains of difficulty falling asl her sleep problems is getting worse and feel tired all at least 4 or 5 nights per week, but states that she is day.She reported she has racing thoughts and before getting to bed she start feeling nervous and stressing about future.Denies taking any day naps.She reported able to stay asleep without difficulty. On average s sleeps 4 or 5 hours per night and awakens at 8:00a daily. She states that she has a fairly consistent 4-5 nights in a week she has troubled sleeping.Denies schedule on weekdays and weekends. She does not taking alcohol or drugs before going to bed.She take any prescription or over the counter sleep aids reported she had sleeping problems in past right after her father passed away.She reported she has to take She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses CPA exam and ever since she has been nervous.She decreased feelings of sleepiness over the past mont reports she usually is a good sleeper.She denies She denies difficulties awaking, but does not feel drinking coffee.She regularly drinks diet cokes.She rested in the morning and has daytime fatigue (rate reported she used alcohol last weekend with her 5/10 severity), restlessness, and irritability (rates 2/ friends.She reports her sleep pattern as getting into severity). She does not take naps. Social History: S bed at midnight and reading books before going to states that she has some stress related to her bed.She denies any history of anviety ,panic upcoming examinations and her impending job sea attacks,depression,psychiatric illness,schizophrenia.She reports she reads a lot,she upon graduation. She states that she has a strong support system made up of friends and family and like to go to Church and with friends.She reports she is active in her church. She states that she copes wi lives with her mom and sister and maintain a good relationship.She has past medical history of Asthma and Diabetes.She uses Proventil inhaler and FLovent stress by staying organized. She enjoys reading an watching television (1-2 hours per day). She states that her father died in a car accident a year and a h inhaler.She is allergic to Peniciilin and Cats.She ago, which was difficult for her and she experience denies smoking cigarettes or ony substance abuse.She some difficulties with sleep at that time as well. Sh reports she is not sexually active currently.She denies any suicidal behavviors.She denies family history of sleep problems,anxiety,psychiatric illness,suicidal behaviors.She denies any developmental delays. denies use of tobacco. She drinks approximately 1 12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does exercise regularly, but states that her job is somew active and she walks 5-15 minutes daily. She drink 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and nig sweats. Does complain of increasing daytime fatig • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in Diagnostics • None at this time Medication • No R at this time • Initiate Melatonin between 0.5 - 5 mg per day taken 30 minutes before sleep Education • Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to ne visit • Encourage to decrease caffeine consumption Plan Encourage relaxation tecniques like deep breathing exercises,yoga,guided imagery and monitor symptoms and log the episodes of insomnia. Encourage to decrease the use of soda. Seek emergent care if the symptoms worsens or feeling of self harm. Encourage regular exercises. and increase intake of water and other fluids • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery • Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activitie after 8pm, and to get out of bed if awaken in the middle of the night • Educate to limit alcohol and depressant medications (including diphenhydramin and Tylenol PM) Referral/Consultation • Consultat with appropriate mental health professional for counselling, cognitive behavioral therapy, or pharmacologic intervention Follow-up Planning • Educate Tina to seek further or emergent care if sh has feelings of self-harm or hopelessness • Revisit clinic in 2-4 weeks for follow up and evaluation. Click to return to main page content. © Shadow Health® 2018 (800) 860­3241 | Help Desk | Terms of Service | Privacy Policy