Reference is optional

Question Answered step-by-step Reference is optional Assign DSM-5 and ICD-10 codes to services… Reference is optionalAssign DSM-5 and ICD-10 codes to services below:1)    Medication:   •     Increase fluoxetine 40mg po daily for PTSD #30 1 RF•     Continue with atomoxetine 80mg po daily for ADHD. #30 1 RFInstructed to call and report any adverse reactions. Future Plan: monitor for decrease re-experiencing, hyperarousal, and avoidance symptoms; monitor for improved concentration, less mistakes, less forgetful 2)    Education: Risks and benefits of medications are discussed including non-treatment. Potential side effects of medications discussed. Verbal informed consent obtained.Not to drive or operate dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing with providers.Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Praised and encouraged ongoing abstinence. Maintain support system, sponsors, and meetings. Discussed how drugs/ETOH affects mental health, physical health, sleep architecture.3)    Patient was educated about therapy and services of the MHC including emergent care. Referral was sent via email to therapy team for PET treatment.4)    Patient has emergency numbers: Emergency Services 911, the national Crisis Line 800-273-TALK, the MHC Crisis Clinic. Patient was instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.5)    Time allowed for questions and answers provided. Provided supportive listening. Patient appeared to understand discussion and appears to have capacity for decision making via verbal conversation. 6)    RTC in 30 days   7)    Follow up with PCP for GI upset and headaches, reviewed PCP history and physical dated one week ago and include lab resultsPatient is amenable with this plan and agrees to follow treatment regimen as discussed.  Health Science Science Nursing NRNP 6675 Share QuestionEmailCopy link Comments (0)