DSM 5
Diagnostic formulation is
The providers assessment of pt rather than a restatement of factors?
The reader should be able to review the information included in the HPI and psychiatric Hx and arrive at the _________ conclusion as the ___________ interviewer
same, original
Is the tx __________ for dx provided?
Appropriate
DSM 5 TR is similar to a _________ and with each ______ listed as a DX
cookbook, ingredient
Plans should include?
pharmacologic, nonpharmacologic interventions,
pt family teaching education
major medication side effects
BBW if any
The length of the eval will depend on the _________ of the pt
complexity of the pt
DX must be based on _________ facts as it guides treatment
objective
we treat _________ not DX
Symptoms
PMHNP must rule in/rule out a dx by if the required sxs are ________ or ____
present , not
Evaluation
know your audience and purpose
The following are:
discussion of Dx
pertinent details of sx present or not present according to DSM 5 TR
basic details regarding situation and background
plan of treatment
estimate prognosis
Essential inclusion of Dx formulation
Multiple dxs may be identified. the most _________ dx should be listed first
pertinent/pressing
ex. in SUD tx that must be listed 1st or in a psych unit psych dx listed first
It is important to do your __________ to come to same conclusions if pt is new to your facility
workup
Psychiatric evaluations can be used for
court -forensic
child custody
protective service
malpractice claim
DSM 5 TR criteria is a dx rendered are __________ in the evaluation
included
Diagnostic formula serves as a "_______ ____ ____" aspect of psych eval
Thinking out loud
provides dx, identity, and justification
All dxs must be ___________
supported
considering possible dx that should is called
ruling in/ ruling out
Plan
Evaluation should be
congruent
internal consistency
logical presentation
The psychiatric eval and MSE should provide __________ for DX
evidence
Is the dx supported ________ documented
history
list should be ________ sized and _________ by finding in the ________ ______
reasonably, supported, psychiatric eval
If a pt is dx with psychotic disorder. the pt should be on an ?
antipsychotic
Make the documentation make sense.