Directions Throughout Your Career You Will Often Be Asked To

Directions throughout Your Career You Will Often Be Asked To Consult

Throughout your career, you will often be asked to consult on patients and provide various letters. Some examples include a primary care provider who may ask you to see their patient who they feel is too young or too complex for them to manage. When they have referred this patient to you, it is a professional courtesy to write a letter thanking them for the referral, explaining your diagnosis and treatment plans (remember has to be a psychiatric diagnosis). Patients may ask you to write letters to the school or to their employer to excuse an absence or for school/ work accommodations. These are appropriate requests; however, you need to be aware that you must not violate HIPAA laws when writing these letters.

For your signature assignment, choose a patient that you have seen during your clinicals to write a professional letter. The letter can either be: · a consultation letter that you would send back to a primary care provider who referred a patient to you to update them on the status of the patient or · a school/ work for recommendations for a patient who needs special accommodations, FMLA, IEP, or 504. Review the rubric for more information on how your assignment will be graded.

Please follow rubric NURS 687L Signature Assignment Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome Identifies nature of letter 30 pts Proficient Provides an opening statement in which the nature of the letter is identified- either giving individualized work or school physical limitations/ recommendations or thanking a referring provider. 22.5 pts Acceptable The opening statement is vague in providing the reason for the letter. 0 pts Missing The nature of the letter is not provided in a statement. 30 pts This criterion is linked to a Learning Outcome Confirms authorization for release of information 30 pts Proficient Provides a statement confirming the patient has provided a HIPAA release which authorizes release of information. 0 pts Missing Does not provide a statement confirming the patient has provided a HIPAA release which authorizes release of information. 30 pts This criterion is linked to a Learning Outcome Impression 80 pts Proficient Provides a concise discussion of the of the diagnosis that is appropriate for the situation and recipient of the letter. 60 pts Acceptable Provides a discussion of the of the diagnosis with some with some minor errors or that is not appropriate for the intended recipient. 40 pts Needs Improvement The discussion of the diagnosis is vague, missing, or inappropriate for the intended recipient of the letter. 20 pts Unsatisfactory More than one element is vague, missing, or inappropriate for the intended recipient of the letter. 0 pts Missing No impression provided. 80 pts This criterion is linked to a Learning Outcome Treatment Plan 80 pts Proficient Describes a detailed plan for medications and laboratory orders that are clearly related to the primary diagnosis. The medications include all prescribing details. If labs are ordered, they are appropriate for the diagnosis and medication. 60 pts Acceptable Describes a detailed plan for medications and laboratory orders (if indicated). Some details may be vague or not clearly relevant to the primary diagnosis. 40 pts Needs Improvement Describes a general plan for medications and laboratory orders. There are several key missing details or items not relevant to the primary diagnosis. 20 pts Unsatisfactory Describes a general plan for medications and laboratory orders that contains errors or is incorrect for the primary diagnosis. 0 pts Missing No medications and laboratory orders provided. 80 pts This criterion is linked to a Learning Outcome Organization/ Professionalism 20 pts Proficient The note is well organized, succinct, and uses professional terms. 15 pts Acceptable The letter is mostly organized and with 1-2 minor mistakes in grammar or placement of information. 10 pts Needs Improvement Several mistakes in placement of information or word choice that impact the organization and clarity of the letter. 5 pts Unsatisfactory Numerous mistakes in wording and placement of information. The letter is not well organized, unprofessional and is difficult to understand. 0 pts Missing Information unreadable, multiple mistakes in organization of data, information is unclear. 20 pts Total Points: 240

Paper For Above instruction

Sample Psychiatric Consultation Letter

[Your Name]

[Your Title/Position]

[Your Address]

[City, State, ZIP]

[Email Address]

[Phone Number]

[Date]

Dr. [Referring Provider’s Name]

[Referring Provider’s Address]

[City, State, ZIP]

Dear Dr. [Referring Provider’s Last Name],

I am writing to formally update you on the condition of your patient, [Patient's Name], whom you referred to me for psychiatric evaluation and management. Prior to sharing sensitive information, I confirm that I have obtained the patient's consent via a HIPAA Release Authorization form, which is included in the patient's medical records.

Patient [Patient’s Name], a [age]-year-old [gender], was seen in my clinic on [date] for complaints of persistent anxiety, difficulty concentrating, and episodes of mood instability. After conducting a comprehensive psychiatric assessment, I diagnosed the patient with Generalized Anxiety Disorder (F41.1) accompanied by episodes of Major Depressive Disorder, recurrent, moderate (F33.1). The diagnosis aligns with the patient's reported symptoms and clinical presentation.

The patient’s mental health disorders significantly impair their daily functioning, including their ability to perform work duties effectively. As such, a tailored treatment plan has been developed to address their condition comprehensively.

Medication management includes initiating Sertraline 50 mg once daily, with plans to titrate gradually based on response and tolerability. The patient is also advised to undergo baseline laboratory testing, including a Complete Blood Count (CBC), Liver Function Tests (LFTs), and a Pregnancy Test for female patients of childbearing age, prior to medication initiation. Follow-up appointments are scheduled every four weeks to monitor medication efficacy and side effects.

Psychotherapeutic interventions, specifically cognitive-behavioral therapy (CBT), have been recommended to complement pharmacotherapy. The patient has been educated on medication adherence, potential side effects, and the importance of regular therapy sessions.

Based on the patient’s current presentation and diagnosis, I recommend consideration for workplace accommodation under the Americans with Disabilities Act (ADA), including flexible work hours and a quiet workspace. These accommodations would support the patient's ongoing treatment and promote optimal functioning at their workplace.

If further information is needed, please do not hesitate to contact me directly at [your phone number] or [your email].

Thank you for referring this patient. I will continue to monitor and manage their psychiatric care and will keep you informed of any significant developments.

Sincerely,

[Your Full Name]

[Your Credentials]

[Your Professional Title]

[Your Contact Information]

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
2. Gelenberg, A.J. (2014). Normative data for depression screening tools. Journal of Clinical Psychiatry, 75(4), 513-522.
3. National Institute of Mental Health (2021). Major depression. https://www.nimh.nih.gov/health/statistics/major-depression
4. Stahl, S. M. (2017). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).
5. U.S. Department of Labor. (n.d.). Americans with Disabilities Act (ADA). https://www.ada.gov/
6. Sachs, G. S., et al. (2016). Tricyclic antidepressants. American Journal of Psychiatry, 173(12), 1177-1184.
7. Harvard Medical School. (2016). Understanding anxiety disorders. Harvard Health Publishing.
8. Gelenberg, A.J., et al. (2010). Consensus recommendations for a major depressive disorder treatment guideline. Journal of Clinical Psychiatry, 71(5), 601-612.
9. Kessler, R. C., et al. (2015). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders. Archives of General Psychiatry, 62(6), 593–602.
10. World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. WHO.