NR 548 | NR548 WEEK 1-6 PRACTICE EXAM | PSYCHIATRIC ASSESSMENT FOR THE PSYCHIATRICMENTAL HEALTH LATEST 2024

NR 548 | NR548 WEEK 1-6 PRACTICE EXAM | PSYCHIATRIC ASSESSMENT FOR THE PSYCHIATRICMENTAL HEALTH LATEST 2024 [Document subtitle] [DATE] [COMPANY NAME] [Company address]What are the 3 phases of psychiatric interview ? 1. Introduction and Building Trust (Engagement Phase) Make the patient feel comfortable and safe so they can open up. What Happens: • You introduce yourself and explain why you’re talking to them (e.g., "I’m here to understand how you’re feeling and how we can help"). • You reassure them that what they share is private and ask for their permission to continue. • You start with open questions like, "Can you tell me what’s been going on?" to let them share their story in their own words. • You listen carefully, show empathy, and pay attention to how they look and act (e.g., are they nervous, sad, or restless?). This phase is all about creating a connection so the patient feels heard and respected. 2. Gathering Information (Exploration Phase) Understand the patient’s problems, background, and experiences. What Happens: • You ask about their main concerns (e.g., "What’s been bothering you the most?"). • You dig deeper into their symptoms—when they started, how bad they are, and how they affect their life. • You ask about their past mental health (e.g., "Have you ever felt this way before?"), any treatments they’ve had, or if they’ve been hospitalized. • You also ask about their physical health, family history, and life situation (e.g., work, relationships, support system). • You check for any risks, like thoughts of self-harm or substance use, to make sure they’re safe. This phase helps you piece together their story and figure out what might be going on. 3. Mental Status Exam (Assessment Phase) Get a snapshot of their current mental state. What Happens: • You observe how they look and act (e.g., are they well-dressed, making eye contact, or fidgeting?).• You ask about their mood (e.g., "How would you describe your mood lately?") and notice how they express emotions. • You listen to how they talk—is it fast, slow, clear, or confusing? • You explore their thoughts—are they logical? Do they have any unusual beliefs or worries? • You check their thinking skills (e.g., "Do you know where you are right now?" or "Can you remember what you had for breakfast?"). • Finally, you assess their understanding of their situation and their ability to make decisions. This phase helps you identify any signs of mental health issues and how they’re affecting the patient. A major medical illness or surgery may precipitate a psychiatric disturbance, while underlying medical conditions will inform diagnosis and treatment decisions. Why should the PMHNP conduct a brief review of systems? The provider may ask focused questions to determine the need for a medical referral or diagnostic testing; therefore, the PMHNP should conduct a brief review of systems (ROS). Medical diagnoses may present with psychiatric symptoms, including but not limited to: • Hyperthyroidism: Anxiety, panic attacks, and mood swings. • Hypothyroidism: Depression, difficulty sleeping, and loss of appetite. • Diabetes: Mood disturbances. Mental Status defined as "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community"Consciousness Being aware of one's own existence, feelings, and thoughts and of the environment. This is the most elementary of mental status functions. Language Using the voice to communicate one's thoughts and feelings. This is a basic tool of humans, and its loss has a heavy social impact on the individual. Mood and affect Both of these elements deal with the prevailing feelings. Affect temporary expression of feelings or state of mind mood more durable, a prolonged display of feelings that color the whole emotional life. Orientation The awareness of the objective world in relation to the self. Able to name own person, place, and timeAttention The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli. Memory The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events remote memory brings up years' worth of experiences. Abstract reasoning Pondering a deeper meaning beyond the concrete and literal. Thought process The way a person thinks; the logical train of thought. Thought content What the person thinks—specific ideas, beliefs, the use of words.Perceptions An awareness of objects through the five senses. The mental status exam (MSE) is the best tool for establishing a psychiatric diagnosis. The MSE includes a combination of observations, impressions, and the interpretation of client responses and is analogous to the physical exam in the formulation of an accurate diagnosis. Components of the mental status exam include •: appearance• behavior• speech• mood• affect• thought process• thought content• cognition• insight/judgment appearance provides important clues about their mental status. Assessment of appearancce involves the observation and documentation of posture, dress, grooming, physical appearance (including distinguishable markings such as scars or tattoos), facial expressions, level of alertness, and attitudes.Cultural Considerations A client's dress or tattoos can reflect culture. For example, in the Samoan and Hawaiian cultures, men sometimes wear a pareo which resembles a skirt. Tattoos may symbolize a client's cultural identity or beliefs Behavior refers to how the client presents themselves during the examination. Assessment of behavior eye contact, psychomotor activity (increased or decreased), movements, mannerisms, stereotypies, and posturing. Behavioral assessment: Observe how the client responds to the exam. Are their responses appropriate to the topics? Can they sit still through the exam? Observe the client's gait as they walk into the office. Are their movements coordinated, slowed, or excessive? Speech Speech is an important diagnostic indicator. Assessment of speech general speech qualities including rate, rhythm, latency, volume, and content.Is the speech fast or slow? rate Is the speech monotone or slurred? rhythm Are there increased or decreased pauses between questions and answers? latency Is the speech soft, normal, or loud? volume Speech patterns diagnostic indicators of a mental health issue when considered in the context of other assessment findings. For example, an individual who presents with an extremely rapid and pressured speech with constant interruptions may be experiencing ＿＿＿ or ＿＿＿ hypomania or mania An absence of speech is seen with some diagnoses such as dementianon-sensical speech is often associated with psychotic disorders. Mood client's state of mind or prevalent emotional state. typically self-reported mood Stable is a good descriptor for mood is appropriate to their current situation. words used to describe mood bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric. Affect physical manifestation of the client's emotional state as observed by the provider. affect descriptors normal, blunted, bizarre, dysphoric, or euphoric.Stability Is the client's affect stable or labile? Appropriateness of affect Is the client's affect suitable for the content discussed? Range Is there a change in affect when describing different situations? Intensity Is there a change in facial expressions or is affect blunted or flat? Thought processes involve the rate of thoughts and how they flow and are connected. Normal thought processes linear and goal-directed. thought processes descriptions loose, circumstantial, or tangential.Clients may experience a flight of ideas little connection between thoughts or words. Assessment of thought processes involves questioning the client and listening to responses. thought processing may be slowed resulting in a delayed response to questioning in patients with ＿＿＿ traumatic brain injuries Assessment of thought content examines themes, presence of of delusional, suicidal, or homicidal thoughts, intensity, specificity. Delusions fixed, false ideas that do not correspond to reality and are not part of a cultural belief system and may be indicative of several mental health diagnoses. Thought content assessment listening closely throughout the exam and through focused questioning.Suicidal and Homicidal Ideation vital component of the mental status exam. Suicide risk assessment likelihood of a client attempting suicide or self-harm. should be used to assess suicide preoccupation and planning Direct terms When assessing for suicidal ideations, should also assess for homicidal ideation, intent, attempts, and plans. critical to determine whether a plan exists assessing for suicidal or homicidal ideations determine if the client has access to the resources needed to execute the plan assessing for suicidal or homicidal ideations The more detailed and thorough the plan higher the risk for suicidal or homicidal ideationsIt is important to assess whether the plan is composed of fleeting thoughts rather than action steps It is important to assess whether the patient is angry and lashing out or intending to bring actual harm. To find out if the client is having suicidal thinking, what is an important question to ask? "Have you ever had any thoughts of hurting yourself or suicide?" How would you respond to a patient who states thy have thoughts of hurting self? Tell me more about those thoughts. Do you have a specific plan in mind for what you would do?" "How easy would it be for you to do this? Do you have access to a gun to follow through with your plan?" "What is it that holds you back from actually doing this? What are the reasons that you stop from trying to hurt yourself?" If the client states that they have access to a gun and a plan for using it, the plan of action for the safety of the client that is in an outpatient setting versus inpatient setting outpatient setting, hospitalization is likely. inpatient setting, they are not ready for discharge.Cognitive assessment evaluation of a client's level of awareness, attention, concentration, and memory. Assessment of memory includes immediate recall, short-term, and long-term memory Awareness assessed through observation with emphasis on the client's eyes and speech. Observation of alertness or wakefulness provides information about cognitive function and can help rule out potential substance use or intoxication. Documentation used to describe levels of awareness include alert and oriented, somnolent, drowsy, comatose. Mini-Mental State Exam (MMSE) is a 30-point questionnaire Mini-Mental State Exam (MMSE) measures cognitive impairment in the areas of orientation, attention, memory, language, and visual-spatial skills.Mini-Mental State Exam (MMSE) easy to administer, available in a variety of languages, requires no equipment Mini-Mental State Exam (MMSE) can be used to detect deterioration in functioning over time. What can impact the score of Mini-Mental State Exam (MMSE) age, education, visual or hearing impairment may impact scores. How might educational levels impact the results of the Mini-Mental State Exam (MMSE)? Asking someone to spell a word backward or complete complicated math questions may be easier for someone who completed high school or post-secondary education. Mini-Mental State Exam (MMSE) Biased against people with poor education due to elements of language and mathematical testing Mini-Mental State Exam (MMSE) Biased against visually impaired, Mini-Mental State Exam (MMSE)Limited examination of visuospatial cognitive ability Mini-Mental State Exam (MMSE) Poor sensitivity at detected mild/early dementia Insight and Judgment final components of the mental status exam. Insight client's awareness of their illness or situation MSE Insight and Judgment -final components of the mental status exam determined to be good, limited, or poor judgement and insight judgment ability to anticipate the consequences of their behavior and safeguard their -cog total Possible Score: 0-5 mini-cog score obtained from adding the 3-item recall and clock drawing scores together. Recall Score Total Possible Score: 0-3, 1 point for each word correctly recalled Clock Drawing Score Total Possible Score: 0-2, 2 points for normal clock, must include all numbers, 1-12, and 2 hands present, one pointing to the 11 and one pointing to the 2, 0 points for abnormal clock Mini-Cog exam score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment Mini-Cog exam score of 3, 4, or 5 indicates lower likelihood of dementia Personal Knowledgememory of remote personal events Cognitively intact patients should be able to tell you Current address and phone number, Names and ages of spouse, siblings, and children, Spouse's birthday, wedding anniversary, and date and place of marriage (if married), Parents' names and birthdays (primarily for younger patients who are not married) Mental Status Exam (MSE) -best tool for establishing a psychiatric diagnosis -combination of observations, impressions, & interpretation of client responses -Eval of patients: • appearance • behavior • speech • affect • thought process • thought content • cognition mental health "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" mental status-refers to emotional (feeling) and cognitive (knowing) function -functioning is inferred through assessment of an individual's behaviors: • consciousness • language • mood and affect • orientation • attention • memory • abstract reasoning • thought process • thought content • perceptions Factors that affect the interpretation of the MSE culture native language educational level literacy social factors MSE: Appearance -posture -dress -grooming -physical appearance • distinguishable markings; scars or tattoos-facial expressions level of alertness -attitudes -Self-esteem -Personal statement MSE: Behavior how the client presents themselves during the examination -eye contact -psychomotor activity • increased or decreased -movements -mannerisms -stereotypies -posturing -how the client responds to the exam • responses appropriate to topics? • sit still through exam? -gait -movements • coordinated, slowed, excessive MSE: Speech Assess general speech qualities: -rate • fast, rapidly, slowly-rhythm • monotone or slurred -latency -volume • soft, normal, or loud -content -increased or decreased pauses between questions and answers? -General quality individual who presents with an extremely rapid and pressured speech with constant interruptions may be experiencing __________ or __________ hypomania or mania An absence of speech is seen with some diagnoses such as ___________ dementia non-sensical speech is often associated with _______________ psychotic disorders MSE: Mood and Affect Mood -client's state of mind or prevalent emotional state -subjective -typically self-reported-Stable: mood is appropriate to their current situation -other: bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric Affect -physical manifestation of the client's emotional state as observed by the provider -normal, blunted, flat, bizarre, dysphoric, or euphoric -Qualities of affect • stability (stable or labile) • appropriateness • range (does it change with diff. situations) • intensity MSE: Thought Process -rate of thoughts and how they flow and are connected -coherent vs. incoherent -Normal: linear & goal-directed -Other: loose, circumstantial, or tangential -Clients may experience flight of ideas with little connection between thoughts or words -Assessment: questioning client, listening to responses MSE: Suicidal and Homicidal Ideation -Direct terms should be used to assess suicide preoccupation and planning -assess for homicidal ideation, intent, attempts, and plans -critical to determine whether a plan exists • access to the resources needed to execute the plan • more detailed and thorough the plan, the higher the risk• assess if plan is composed of fleeting thoughts rather than action steps • assess whether the client is angry and lashing out or intending to bring actual harm -SCREENING FOR SUICIDAL AND HOMICIDAL IDEATIONS IS AN ETHICAL OBLIGATION OF THE PMHNP & IS ESSENTIAL FOR PROTECTING ONESELF, THE CLIENT, & THE PUBLIC MSE: Cognitive Assessment -evaluation of a client's level of awareness, attention, concentration, and memory -Awareness: observation with emphasis on the client's eyes and speech -alertness or wakefulness provides information about cognitive function • help rule out potential substance use or intoxication -levels of awareness: alert and oriented, somnolent, drowsy, or even comatose -Attention and concentration: observation of responses during the interview • can they stay on topic? • able to focus and respond to Q's? • can use standardized tools such as the Mini-Mental State Exam (MMSE), digit span test and the SSST -Memory assessment: immediate recall, short-term, and long-term memory • particularly important when ruling out dementia or Alzheimer's disease • Stress, anxiety, and depression can also impact memory • orientation, three-object recall -Mini-Cog exam is commonly used to help rule out significant cognitive issues Two attention and concentration assessments digit span test -patient is given 5-7 numbers & asked to repeat them forward and backwardSSST -pt asked to subtract 7 from 100 and to continue counting back by 7s until told to stop *research studies have not endorsed them -SSST given to 132 normal adults, only 42% with errorless performance -325 hospitalized psychiatric pts given SSST, no diff. in performance from 50 healthy control subjects -Digit span test among 60 elderly pts with memory impairment and 44 elderly who were healthy found no difference MMSE -Mini-Mental State Exam -30-point questionnaire -measures cognitive impairment in the areas of orientation, attention, memory, language, and visual-spatial skills -method of monitoring deterioration over time -age, education, and visual or hearing impairment may impact scores • Most studies have defined poorly educated as 8 or fewer years of education—that is, no high school -sensitivity of the test is high, specificity is low Interpret a mini-cog score (Total Possible Score: 0-5): Add the 3-item recall and clock drawing scores together. Recall Score (Total Possible Score: 0-3) -1 point for each word correctly recalledClock Drawing Score (Total Possible Score: 0-2) -2 points for normal clock (include all numbers, 1-12) -0 points for abnormal clock -must be 2 hands present (one pointing to the 11 and one pointing to 2) -hand length not scored Mini-Cog exam -streamlined dementia screen -score range is from 0-5 -obtained from adding the 3-item recall and clock drawing scores together. -A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment -A total score of 3, 4, or 5 indicates lower likelihood of dementia • does not rule out some degree of cognitive impairment. three object recall Recall of three objects after at least 2 minutes has been shown to be a useful test in diagnosing cognitive impairments -Repeat the following three words: ball, chair, purple. -Once you are satisfied that your patient has registered all three words, say: Now I want you to remember those three words, because I'm going to ask you to repeat them in a couple of minutes. -In the meantime, ask your patient general knowledge questions bout general cultural and personal information. -Then ask him to repeat the three words. -If trouble, use the following hints: • One of them is something you can play with• One is a piece of furniture. • One is a color. General Cultural Knowledge Inability to recall at least half of these items is presumptive evidence of long-term memory impairment. -Last three presidents -famous figures • George Washington, first president • Abraham Lincoln, freed the slaves • Martin Luther King, Jr., civil rights leader • Princess Diana, British princess killed in car accident • William Shakespeare, writer • Christopher Columbus, discovered America -Famous dates • When did World War II happen? (Any time in the 1930s or 1940s is adequate.) • When was John F. Kennedy assassinated? (Sometime in the 1960s.) -Lists of information • screening for dementia is the set test: patient to name as many items (up to ten) as he can recall in each of four categories: colors, animals, fruits, and towns; max of 40, score of 25 or above excludes dx of dementia Personal Knowledge memory of remote personal events -Cognitively intact patients should be able to tell you: • Current address and phone number • Names and ages of spouse, siblings, and children• Spouse's birthday, wedding anniversary, and date and place of marriage (if married) • Parents' names and birthdays (primarily for younger patients who are not married) MSE: Insight and Judgment -final components of the mental status exam -determined to be good, limited, or poor depending on the actions the client has taken, awareness of their illness, and the plans they have for the future. Insight -client's awareness of their illness or situation Judgment -ability to anticipate the consequences of their behavior and safeguard their well-being -may be measured with a standard question but should be assessed throughout the entire interview Q's to probe for degree of insight -So, why do you think you've been having these problems? -What do you think needs to happen for your life to improve? Pt's with poor insight may respond with: -I don't know. You're the doctor. -People need to stop hassling me. (A paranoid patient.) ABSATTC Mnemonic for Elements of the Mental Status Examination-All Borderline Subjects Are Tough, Troubled Characters • Appearance • Behavior • Speech • Affect • Thought process • Thought content • Cognitive examination closure -final phase of the psychiatric interview process -provides the client with a summary and findings of the interview and allows for discussion of future plans -PMHNP may provide education during this phase final step of the psychiatric interview documentation -Thorough, accurate documentation is necessary for clinical and legal purposes Closing the Interview PMHNP explains the diagnosis and treatment options to the client -offers an opportunity for the client to ask questions and give input -discussion includes recommendations for any additional psychological assessments and laboratory testing needed -education regarding recommended medications and therapies-If a need to collaborate with other providers for information or treatment, the PMHNP should seek permission from the client at this time to do so -opportunity to address any client concerns about stigma -discuss need for F/U care Which of the following should be included when providing client education about medication regimens? Select all that apply. explain how the medication targets the symptoms, specific benefits, and expected time course. identify potential side effects, duration of side effects, and adverse effects. explain the instructions, dosing, and special requirements. use teach-back methods to ensure client understanding. explain how the medication targets the symptoms, specific benefits, and expected time course. identify potential side effects, duration of side effects, and adverse effects. explain the instructions, dosing, and special requirements. use teach-back methods to ensure client understanding. Follow-Up homework PMHNP may assign homework to the client -especially when tx plan includes cognitive-behavioral or family therapy -explain the purpose and goal of the assignment -explain whether the client will be expected to report on the homework at the next appointmentFollow-Up care PMHNP should discuss the need for follow-up care with the client during the closure of the interview -include clients in determining the need for and frequency of follow-up visits • promote adherence -Two-week intervals are common when starting new medications • assess for tolerability, efficacy, and the need for dose adjustment -four-week intervals (or longer) are typical for stable clients -Scheduling future visits is important as noncompliance is common in mental health Documentation Use the ten minutes following the 50-minute interview to record clinical findings -facilitates communication with other members of the healthcare team -provides information to insurance companies and third parties for billing and reimbursement -required to satisfy legal requirements and mitigate risk • Careful and thorough record-keeping is imperative in the event of litigation All components of a clinical encounter should be documented including: • chief complaint • referral source • history of present illness • current treatments including medications and therapies • past medical, family, social histories • review of systems• mental status examination • diagnosis • treatment plan SOAP note subjective, objective, assessment, and plan method of documentation that helps organize the information from a psychiatric interview three objectives for clinical documentation -Thoroughness • thorough yet succinct description of the client mindful of presenting an accurate, objective account of the client encounter • Be aware of personal bias -Time efficiency • typically take no more than 10-15 minutes -Readability • 2-3 pages maximum to allow for easy review Identifying Data fairly long initial sentence that sets the stage for the entire evaluation -includes demographic descriptors of the client and the context of the referral• age, sex, marital status, and source of referral at a minimum • may include other information such as occupation, living situation, and presence of other family. Chief Complaint reason client gives for presenting for treatment at this time; typically, a direct quotation or subjective statement History of Present Illness -recent psychiatric symptoms, including pertinent positives and negatives -includes timeframe of recent onset or exacerbation, symptom triggers, or recent treatment and treatment changes providing a snapshot of the onset and progression of the current issue Past Psychiatric History (PPH) includes psychiatric hospitalizations, outpatient treatments, current and past medications, types of psychotherapy, and any suicide and/or violence history spanning early childhood to the present -Can use mnemonic Go CHaMP for write-up • General statement • Caregivers • Hospitalizations • Medication trials • past Psychotherapy (include if it was helpful, why/why not) Substance Use History-includes drug and alcohol use, when used, consequences of use, the recent pattern of use, last use, and treatment -also includes nicotine and caffeine usage Review of Symptoms -includes screening for present and past symptoms related to the diagnostic category -section assists in defending and confirming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5-TR) diagnosis. -go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, if you have included one Family History -includes history of psychiatric disorders, substance abuse, and suicide in the client's family -provides an understanding of the client's home life, their childhood experiences, education, and relationships -genogram will suffice for family psychiatric hx Social hx At a minimum: -Where your patient was born and raised -Number of siblings -Birth order of patient and siblings -Who was present in the household during the formative years -Educational level -Work history-Marital and parenting history of patient -Typical daily activities other than work Medical History includes significant medical illnesses, hospitalizations, surgeries, seizures, head injuries with loss of consciousness, and prescribed medications and the primary care provider -may use mnemonic MIDAS -usually begin with general statement about pt's general health Mental Status Exam includes observational and direct inquiry components and requires vivid description -Describe your patient so well that a reader would be able to recognize him from your description alone Assessment -includes the diagnosis -concise and informative -A list of differential diagnoses may be included, but the initial diagnosis listed is the DSM-5 TR diagnosis. DSM-5 TR vs Diagnosis includes all diagnoses involving psychiatric, personality, or medical disordersTreatment Plan includes any diagnostic testing planned, medications, therapy, client education (dosing instructions, side effects, expected benefits, when to note efficacy), referrals, follow-up care How to Educate Your Patient -Briefly state your diagnosis -Find out what your patient knows about the disorder -Give a minilecture about the disorder, if indicated -Ask if there are any questions -Give your patient written educational materials Negotiating a Treatment Plan: Essential Concepts -Elicit the patient's agenda -Negotiate a plan that you and your patient can agree on -Help the patient implement the agreed-on plan Elicit the Patient's Agenda elicit it with a simple question, such as: How do you hope I can help you? How were you hoping that I could help you to feel better? -Sometimes patients have a pretty clear idea of what they'd like; medication, counseling, advice about something, a letter to someone -don't have a specific request or agenda; don't force the issue with these patientsNegotiate a Plan treatment adherence is enhanced when the patient and practitioner agree on the nature of the problem -agree at the outset about a plan, go directly to the implementation phase -must negotiate a mutually agreed-on goal Common problematic request - patient seeks hospitalization for a problem that can be treated in an outpatient setting: What is important to keep in mind? possibility that the patient is suffering much more than originally indicated -their request for hospitalization is their way of obliquely disclosing that. -may need to reassess for SI at this point, if still satisfied that hospitalization is not indicated, discuss other options: • Day hospitalization • Respite care • Staying with a friend or relative for a while if the home situation is intolerable • Taking a few days off from work • Having the patient call you (or another clinician) for daily check-ins during a crisis period • Setting up more frequent appointments • A short course of an antianxiety medication Implementing the Agreed-On Plan likely fall into one or both of the following categories: -follow-up therapy appointment with you or someone else • highest F/U aherence: wait for F/U appt is short, referrals made to specific clinicians rather than to a clinic, specific appt made at time of disposition, pt speaks directly to someone at referral clinic during evaluation session.-Medication trial • Determine how your patient will pay for medication: Some patients can't afford the copays - if so, you may be able to provide samples • Make sure pt understands the side effect profile of the medication • Simplification increases recall and compliance • Having pt repeat what you say increases recall of instructions In 2018, the American Psychiatric Association (APA), in conjunction with the American Telemedicine Association (ATA) developed: best practices for providing videoconferencing-based telepsychiatric care-guidelines inform the technical considerations and administrative requirements needed to provide these services best practices for providing videoconferencing-based telepsychiatric care: -Use of a designated technology platform. Telesessions should not be conducted using alternate platforms; however, an alternate plan, such as a telephone call, may be used in case of technology failure. -Provisions for the verification of confidential and secure client information. -Sufficient bandwidth to provide clear, appropriate video and audio quality. -Device compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state requirements. During telepsychiatry sessions, both the provider and client locations should be treated as a Confidential space During telepsychiatry sessions, provisions must be taken to ensure:-the discussion cannot be overheard by other-adequate lighting and ambiance is provided that is appropriate to the session -place the camera so that the eyes and face of the participants are visible Telepsychiatry Legal and Regulatory Considerations: Best practices -Malpractice insurance-Licensure requirements-Federal and state prescribing guidelines -Reimbursement Telepsychiatry Legal and Regulatory Considerations: Malpractice insurance Malpractice insurance is required and some policies require additional policies for telehealth. Telepsychiatry Legal and Regulatory Considerations: Licensure requirements Licensure requirements differ from in-person practice.-Providers must hold a license to practice in the state where the client resides.-The PMHNP is responsible for following standards for the state in which they are practicing. Telepsychiatry Legal and Regulatory Considerations: Federal and state prescribing guidelines Federal and state prescribing guidelines differ for telepsychiatry.-The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 governs the prescribing of controlled substances via teleconferencing.• To safely prescribe, the provider must conduct an in-person medical evaluation at least once every 24 months and comply with all federal and state prescribing guidelines. Telepsychiatry Legal and Regulatory Considerations: Billing and Reimbursement-Reimbursement varies by state and insurance provider.• Currently, 48 states provide Medicaid reimbursement for telepsychiatry services.-pt made aware of any and all financial charges that may arise from the services prior to the commencement of initial services Best practices for determining the appropriateness of telepsychiatry services include consideration of the following: -cognitive capacity of the client-client history and medical status -geographic distance to emergency facilities -client support system Best practices related to special populations: Forensic and Correctional -follow applicable standards of consent in terms of client's legal status and rights - develop clear, site-specific protocols Telemental health Children and Adolescents: environment should facilitate the assessment by providing an adequate room size, furniture arrangement, toys, and activities that allow the youth to engage with the accompanying parent, presenter, and provider and demonstrate age-appropriate skills best practices related to special populations: Children and Adolescents follow the same guidelines presented for adults•modify care based on developmental status (motor functioning, speech and language capabilities, relatedness, and relevant regulatory issues)-include family as appropriate-Providers should consider how the presenter's involvement can affect service delivery -Appropriateness for telemental care shall consider safety of the youth, the availability of supportive adults, the mental health status of those adults, and ability of the site to respond to any urgent or emergent situations.Best practices related to special populations: Geriatric -include family as clinically appropriate-adapt care for cognitive or sensory impairment best practices related to special populations: Military and Veteran -be familiar with federal and organizational structures and guidelines -be familiar with military cultural competence best practices related to special populations: Substance Use Disorder Treatment comply with federal, state, and local regulations related to prescribing controlled substances -coordinate with on-site staff as appropriate to ensure care coordination and monitoring best practices related to special populations: Inpatient and Residential Settings -participate in administration and organizational meetings as appropriate -optimize use of site-staff for consultation and care coordination best practices related to special populations: Primary Care leverage telepsychiatry to support integrated care best practices related to special populations: Rural be aware of impact of rural environments in relation to firearm ownership, kinship, and geographic barriers to careTypically, the standard operating procedures (SOP) addresses: roles, responsibilities, licensing, client identification, and systematic quality improvement. -backup plan to address technical difficulties is frequently included standard protocols to support telepsychiatry services: (4 steps) Step 1: Confirm the name and credentials of provider and the name of the client. Step 2: Identify the location of the client. Step 3: Gather contact information for provider and client in case of interruption of session. Step 4: Provide guidance for appropriate contact between sessions and review emergency management protocols for client.-If client is in a location with clinical staff, the provider will inform staff of emergent situations -If client is in another location, the provider may identify a support person to contact for potential emergencies.-If the client requires emergency intervention in the community setting, the provider must coordinate with local emergency staff. Telehealthcare the use of telecommunications technology to remove time and distance barriers from the delivery of health care services and related health care activities-Traditionally, the use of telehealth and tele-mental health care was designed to meet the needs of rural populations and geographic areas with identified shortages of specialty health care professionals Forensic Mental Health Care Any cross between the criminal justice system and psychiatric nursing can be considered forensic mental health-64% of U.S. inmates have mental health concerns or disorders-15% to 20% of inmates in jails and prisons suffer from serious mental illness-Over 90% of federal inmates with mental health conditions are without access to mental health treatment Informed Consent Local, state, and national laws regarding verbal or written consent shall be followed-If written consent is required, then electronic signatures, assuming these are allowed in the relevant jurisdiction, may be used-The provider shall document the provision of consent in the medical record Informed Consent for care and treatment is a fundamental ethical and legal principle-respects the client's autonomy in medical decision-making-Clients have the right to receive information and ask questions about recommended treatments so they can make decisions about their care that are consistent with their beliefs, values, and goals of treatment-Clients have the right to knowledge about their treatment under "reasonable practitioner" or "reasonable person" standards under U. S. law.-may change over time and in different circumstances• is an ongoing process Steps to Obtaining Informed Consent -Assess client ability to understand medical information & tx options & to make a voluntary decision -Present relevant information with accuracy and sensitivity, Should include information about: • Diagnosis• Nature and purpose of treatment options• Benefits, risks, and burdens of all treatment options, including forgoing treatment -Document informed consent conversation in the medical record, including all consent forms Informed Consent: DocumentationDocumentation of the discussion to obtain informed consent should include: - treatment plans with risks and benefits identified-reasonable alternatives with risks and benefits identified-assessment of client understanding of the discussion *must demonstrate that the client participated in the decision-making process and that the client was not coerced into treatment Exceptions to Informed Consent: -client incapacitation-life-threatening emergencies-voluntary waived consent-client unable to make decisions and has no designated decision-maker -involuntary treatment Clinically unsupervised settings -Providers should discuss the importance of having consistency in where the patient is located for sessions-knowing a patient's location at the time of care, as it impacts emergency management and local available resources • As patients change locations, providers shall be aware of the impact of location on emergency management protocols (police, emergency rooms, crisis teams)-provider should consider the use of a "Patient Support Person" (PSP) as clinically indicated• a family, friend or community member selected by the patient who could be called upon for support in the case of an emergency If a patient and/or a PSP will not cooperate in his or her own emergency management: providers shall be prepared to work with local emergency personnel in case the patient needs emergency services and/or involuntary hospitalization. Care CoordinationWith consent from the patient and in accordance with privacy guidelines, telemental health providers should arrange for appropriate and regular communication with other professionals and organizations involved in the care of the patient. TECHNICAL CONSIDERATIONS: VIDEOCONFERENCING PLATFORM REQUIREMENTS should select video conferencing applications that have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose-event of a technology breakdown, causing a disruption of the session, the professional shall have a backup plan in place (telephone access)-services at a bandwidth and with sufficient resolutions to ensure the quality of the image and/or audio received is appropriate to the services being delivered TECHNICAL CONSIDERATIONS: security issues -policies and procedures in place to ensure the physical security of telehealth equipment and the electronic security of data-Organizations shall ensure compliance with all relevant safety laws, regulations, and codes for technology and technical safety -HIPAA and state privacy requirements shall be followed at all times to protect patient privacy -mental health and substance use disorder services are afforded a higher degree of patients' rights as well as organizational responsibilities (e.g., need for specific consent from patients to release information around substance use) telemental health PHYSICAL LOCATION/ROOM REQUIREMENTS -both locations shall be considered a patient examination room regardless of a room's intended use-Providers shall ensure privacy so clinical discussion cannot be overheard by others outside of the room -patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person-features of the physical environment for both shall be adjusted so the physical space, to the degree possible, maximizes lighting, comfort and ambianceChild & Adolescent Telepsychiatry: Legal and Regulatory Issues Many states require guardian consent, written and/or verbal, for telepsychiatry services in addition to the usual consent for care-reporting requirements may vary by jurisdiction and ensure that relevant personnel at the distant (provider location) and originating (patient location) sites are informed of reporting requirements for youth -Telepsychiatrists should comply with the AACAP Code of Ethics-absence of a comprehensive policy for delivering telemedicine services, individual states have proposed legislation to expand services:• reimbursing for school-based telepsychiatry services• repealing laws that mandate minimum distance requirements between distant and originating sites in order to receive reimbursement Child & Adolescent Telepsychiatry: Patient Safety -·Psychiatrists telecommuting to any setting must consider whether appropriate emergency management protocols are in place and develop any needed protocols.- utilizes the local community's emergency resources-Telesychiatrists managing emergencies must rely on a team of individuals -· need to be able to effectively manipulate telepsychiatry technology in order to maximize video and audio quality to optimally assess signs of agitation, substance use, and medication side effects.• If technology falters, psychiatrists should be prepared to quickly initiate a pre-planned backup emergency management plan. The Ryan Haight Online Consumer Pharmacy Protection Act of 2008 impacts the legitimate practice of child and adolescent telepsychiatry.-requirement for the initial in-person evaluation is a major barrier for telepsychiatry with youth and the exceptions to this requirement are narrow and do not apply to many telepsychiatry applications The Ryan Haight Act is relevant to the increasing trend towards:direct-to-consumer telepsychiatry as the home setting is not an approved site of service for prescribing controlled substances. Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space -starts with the rooms at both the patient's and psychiatrist's sites-rooms should be set up to establish a typical clinical experience-psychiatrist's room should be conservatively appointed both to facilitate the camera's focus and to not distract the patient-patient's room should be of appropriate size to optimally conduct a mental status examination• including observation of gross motor and fine motor skills, affect and relatedness Health Insurance Portability and Accountability Act (HIPAA) provides a legal framework for handling client information-HIPAA rules help protect the privacy of the client's identifiable health information while facilitating communication among providers and other entities• ensure information is available for treatment and other purposes such as insurance benefits -health professionals may be held legally liable by state and federal law for breaching confidentiality HIPPPA- Release of Information -HIPAA guides the PMHNP in making decisions about when to share information based on their professional judgment to prevent harm• may be necessary for providers to share mental and behavioral health information to enhance treatment or ensure the health and safety of the client and others -PMHNPs are mandatory reporters in cases of suspected child abuse Duty to Warn exception to requirements for confidentiality-Most states have laws that allow mental health professionals to share information about clients who may become violentseveral states, it is even mandatory for providers to report when clients may pose a danger to themselves or others Psychotherapy notes, or process notes are treated differently than other types of mental health information and receive special protections under HIPAA psychotherapy notes definition "notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record" Must the PMHNP release a client's medical record to a client's insurer? Yes Must the PMHNP release psychotherapy notes to the client? No Must the PMHNP release medical records to the court with a subpoena? Yes with client authorizationTypes of development the PMHNP should consider include: cognitive and psychosocial development Abraham Maslow's theory regarding human needs may also inform the PMHNP's approach to psychiatric interviewing. Piaget's cognitive stage: Sensorimotor 0-2 years of age• cognitive abilities based on reflexes• children master object permanence and causality Cognitive Development: Piaget's cognitive stages -Sensorimotor -Preoperational -Concrete Operational -Formal Operational Piaget's cognitive stage: Preoperational 2-7 years of age child can use mental representations, symbolic thought, and language • thinking is egocentric Piaget's cognitive stage: Concrete Operational 7-11 years of age child uses logical operations when thinking and solving problems thinking is concreteFormal Operational 12 years and older• adolescent can use abstract reasoning in addition to logical operations can understand theories, hypothesize, and comprehend abstract ideas such as love and justice Psychosocial Development: Erikson's developmental theory individuals go through a series of eight stages of psychosocial development from birth to death -each stage, individuals must resolve a psychosocial crisis to move to the next stage• Unsuccessful resolution could impair the development of a healthy personality and sense of self, which could negatively impact mental health and relationships Erikson's psychosocial stages -Infancy: Trust vs. Mistrust (birth-18 months) -Early Childhood: Autonomy vs. Shame and Doubt (ages 18 months-2 to 3 years) -Preschool: Initiative vs. Guilt (ages 3-5) -School Age: Industry vs. Inferiority (ages 6-11) -Adolescence: Identity vs. Role Confusion (ages 12-18) -Young Adulthood: Intimacy vs. Isolation (ages 19-40) -Middle Adulthood: Generativity vs. Stagnation (ages 40-65) -Maturity: Integrity vs. Despair (ages 65-death) Abraham Maslow's Hierarchy of Needs motivational theory that examines people's behavior as it relates to five categories of needs -Needs arranged in a pyramid, most basic needs at the foundation:• selfactualization (top of pyramid)• esteem• love/social needs• safety• physiological (bottom of pyramid) Special Considerations: Children -Legislation regarding minors and informed consent is based on state law • be familiar with the req in state of practice• Children under 17 typically cannot provide informed consent-Parents must give permission for tx in most circumstances, exceptions: • under 18 and married • serving in the military • able to provide financial independence • mother of a child (married or not) Special consideration: disregarding parental rights -A parent may not be allowed to access info. in the following circumstances: • info. is contained in the therapist's psychotherapy notes• parent not designated as the child's personal representative• parent voluntarily agrees that info can be kept confidential • provider has a reasonable belief that abuse or neglect exists or parent is a danger to the child • provider believes it is not in the child's best interest to treat the parent as the child's representative Interviewing children and adolescents -PMHNP may need to speak with family members separately from the child to gain additional information about the child's mental health concern-Family issues and family dynamics often play a role in the child's or adolescent's psychiatric disorder -Common topics to cover in an adolescent interview include: • interests• school and activities• drug and alcohol use • sexual activity• conduct problems Special Considerations: Older AdultsWhen conducting a psychiatric interview with an older adult, the PMHNP must consider the following:-developmental issues of older adulthood-generational perspectives and beliefs -comorbid physical illness -polypharmacy-cognitive or sensory impairments -history of physical/mental disorders Sociocultural factors that may influence the experience and expression of health and of psychological problems in later life gender race ethnicity socioeconomic status sexual orientation disability status urban/rural residence Older adults: changes that impact cognitive functioning -Sensory deficits, especially vision and hearing -Physical health -Poverty -Medications -Active use of information processing strategies -Lifestyle factors -Neurodegenerative conditions Family Educational Rights and Privacy Act (FERPA)A federal law that governs student confidentiality in schools.-requires that schools not divulge, reveal or share any personally identifiable information about a student or his/her family, unless it is with another school employee who needs the information to work with the student. The American Psychiatric Association (APA, 2020) supports telemedicine as a legitimate component of a mental health delivery system when telepsychiatry services: -benefit the client-maintain client autonomy, confidentiality, and privacy-when used consistent with APA medical ethics policies and established telepsychiatry laws Telepsychiatry services are provided in diverse settings, including: • private practice• outpatient clinics• schools• nursing homes• correctional facilities • military facilities telepsychiatry services are delivered through: • videoconferencing technology • websites• recorded medical information • support or chat groups • asynchronous client-provider interactions social media • links to self-directed or assisted assessment Benefits of telepsychiatry services: • improved access to care• reduced costs• improved efficiency• improved integration of care• decreased emergency department visits • fewer delays in care • improved continuity of care• reduction of transportation-associated barriersTelepsychiatry __________, _________, _________, and _________ outcomes are comparable to in-person services. validity, reliability, assessment, and treatment outcomes most common modalities for providing telepsychiatric services is via videoconferencing technology