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Initial Psychiatric Interview/SOAP Note Template Criteria Clinical Notes Informed Consent Patient was alert, oriented x3 and provided verbal consent to participate in the assessment. Subjective Verify Patient Name: DB DOB: 50-year-old African American female Minor : No Accompanied by : Patient was unaccompanied Demographic : N/A Gender Identifier Note: Female CC : “I have been feeling stable and I'm taking all my medications" HPI : DB is a 50-year-old African American female presenting for a mental health assessment. She reports taking all of her medications and states that her mood is stable. She reports sleeping and appetite are ok. She is currently attending a methadone program 3 days per week and reports taking 47 mg of methadone daily. DB was alert and oriented x3 during assessment, had proper eye contact, and denied any SI/HI or auditory hallucinations. Pertinent history in record and from patient: Patient has a past diagnosis of schizoaffective disorder, bipolar type. During assessment: The patient reports taking all of her medications, sleeping and appetite are okay, and attending a methadone program 3 days per week. Patient reports taking 47 mg of methadone daily, denies any SI/HI or auditory hallucinations, and states her mood is stable SI/ HI/ AV: Patient denies any suicidal or homicidal ideation, auditory or visual hallucinations. Allergies: No allergies reported Past Medical History: No medical history reported Medical history: Denies any past medical issues. Past Psychiatric History: Patient has been previously diagnosed with schizoaffective disorder bipolar type. She reports previous medication trials and has no history of violence to self or others. Previous psychiatric diagnoses: schizoaffective disorder, bipolar type. Patient describes stable mood. Previous medication trials : Patient reports taking 47 mg of methadone daily. Safety concerns History of Violence to self: none reported History of Violence to others: none reported Auditory Hallucinations : Patient denies any auditory hallucinations. Visual Hallucinations: Patient denies any visual hallucinations. Mental health treatment history History of outpatient treatment : Patient reports attending a methadone program 3 days per week and taking 47 mg of methadone daily. Previous psychiatric hospitalizations: No prior psychiatric hospitalizations reported. Prior substance abuse treatment: Patient is attending a methadone program 3 days per week. Trauma history : None reported Substance Use: Patient reports using methadone daily and denies any other substance use. Client report taking 47 mg of methadone daily. Current Medications: 47 MG of methadone Past Psych Med Trials: None reported Family Medical History: Not mentioned Family Psychiatric History: Substance use: No substance use reported Suicides-none Psychiatric diagnoses/hospitalization-none Developmental diagnoses-none Social History: Occupational History: None reported Military service History: Denies previous military history. Education history: No education history reported Developmental History: None reported Legal History: None reported Spiritual/Cultural Considerations : none reported.

ROS: Constitutional : No report of fever or weight loss. Eyes: Eye contact was appropriate during assessment. ENT: No report of hearing loss, tinnitus, or vertigo. Cardiac: No report of chest pain or dyspnea. Respiratory: No report of cough or wheezing. GI: No report of nausea, vomiting, or abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or stiffness. Skin : No report of rash or lesions. Neurologic: No report of weakness, numbness, or dizziness. Hematologic: No report of bleeding or easy bruising. Allergy: No report of allergies. Reproductive: No report of menstrual irregularities. Objective Vital Signs: Stable Temp: 98.6 BP: 120/80 HR: 80 R: 16 O2: 98% Pain: 0/10 Height: 5’9” Weight: 160 lbs. BMI: 25.7 BMI Range: Normal LABS : Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: Negative Physical Exam: MSE: Patient was alert, oriented x3, and had no physical distress noted. Presents with appropriate eye contact. TC: Patient was cooperative and had proper eye contact throughout the assessment. Assessment DSM5 Diagnosis: with ICD-10 codes Dx : Schizoaffective disorder bipolar type Dx : Substance Use Disorder, Moderate The patient meets criteria for schizoaffective disorder bipolar type as per the DSM-5. This disorder is characterized by a period of a major mood episode, either manic or depressive, that occurs with psychotic symptoms. The patient reported having a stable mood, taking all of her medications, and attending a program 3 days per week and methadone clinic. This is indicative of a stable mood disorder. According to the DSM-5, schizoaffective disorder bipolar type is diagnosed when the patient has a period of illness that consists of a major mood episode (either manic or depressive) concurrent with the active-phase symptoms of a schizophrenia spectrum disorder (Noel & Jackson, 2020). Plan (Note some items may only be applicable in the inpatient environment) Inpatient Psychiatric: bipolar as per DSM-5 criteria Estimated stay: 4 days Safety Risk/Plan: Patient is found to be at low risk for violence to self or others and denied any SI/HI or auditory hallucinations. Pharmacologic interventions: The patient should continue her current dosage of 47 MG of methadone daily and should be evaluated for additional medications to help manage her schizoaffective disorder bipolar type. Possible medication interventions include mood stabilizers, antipsychotics, and antidepressants. Mood stabilizers such as lithium, valproic acid, and carbamazepine can help to stabilize mood and reduce manic and depressive episodes. Antipsychotics such as risperidone and olanzapine can be used to reduce psychotic symptoms (Martinotti et al., 2022). Antidepressants such as fluoxetine and sertraline can be used to help manage depressive symptoms. In the case of the patient, she should be evaluated for the need for additional medications to help manage her schizoaffective disorder bipolar type. Referrals: Patient should be referred to a psychiatrist for further management and monitoring of her schizoaffective disorder bipolar type. Follow-up: Patient should follow up with the psychiatrist in 1-2 weeks. Time spent in psychotherapy: Patient should attend weekly psychotherapy sessions Visit lasted : The visit lasted 45 minutes References Martinotti, G., Chiappini, S., Mosca, A., Miuli, A., Santovito, M. C., Pettorruso, M., ... & Giannantonio, M. D. (2022). Atypical antipsychotic drugs in dual disorders: current evidence for clinical practice. Current Pharmaceutical Design, 28(27), . Noel, J. M., & Jackson, C. W. (2020). ASHP therapeutic position statement on the use of antipsychotic medications in the treatment of adults with schizophrenia and schizoaffective disorder. American Journal of Health-System Pharmacy, 77(24), .

Paper For Above instruction

The initial psychiatric assessment of a patient is a crucial step in diagnosing and formulating an effective treatment plan for individuals with complex mental health conditions. In this case, we examine the comprehensive evaluation of DB, a 50-year-old African American woman diagnosed with schizoaffective disorder bipolar type, who is also engaged in opioid maintenance therapy through a methadone program. This assessment integrates subjective and objective data to facilitate a holistic understanding of her mental status and physical health, thereby guiding subsequent interventions and coordination of care.

Introduction

Psychiatric assessments are foundational in establishing diagnoses, monitoring treatment progress, and identifying risks. They involve systematic collection of subjective reports from the patient alongside objective clinical observations. Such evaluations are especially vital for individuals with dual diagnoses, where mental health and substance use disorders intersect, as in the case of DB. The mental health assessment must consider medical history, substance use patterns, psychosocial factors, and safety concerns to form a comprehensive clinical picture.

Subjective Data Collection

DB reports feeling stable and adherent to her medication regimen, which is indicative of a well-managed mood disorder. She denies suicidal ideation (SI), homicidal ideation (HI), auditory, or visual hallucinations, suggesting stability in her psychotic symptoms at the time of assessment. Her claim of sleeping and appetite being "okay" further supports her current functional status. Importantly, her engagement in a methadone program indicates ongoing management of opioid dependence, which complicates but also provides an opportunity to address her psychiatric condition holistically.

Objective Data and Mental Status Examination

The clinical examination reveals a patient who is alert and oriented to person, place, and time, with no physical distress, good eye contact, and cooperative behavior. Her vital signs are within normal limits, and laboratory findings—including toxicology screening—are negative for other substances, confirming medication adherence and lack of recent overdose or intoxication. The mental status exam (MSE) confirms no current hallucinations or paranoid ideation, aligning with her subjective report of stability. These objective findings are crucial in corroborating her expressed experience and inform ongoing management decisions.

Diagnostic Formulation

Using DSM-5 criteria, DB is diagnosed with schizoaffective disorder bipolar type, a condition marked by significant mood episodes concurrent with psychotic features. She also presents with moderate substance use disorder, mainly involving opioids, as evidenced by her methadone treatment. The diagnosis involves considering her mood stability, absence of psychosis or agitation at present, and her history of psychiatric diagnoses and treatment. Accurate diagnosis is critical for selecting appropriate pharmacological and psychosocial interventions.

Management and Treatment Plan

The management plan for DB encompasses pharmacologic and psychotherapeutic strategies tailored to her dual diagnosis. She should continue her current methadone therapy, which addresses her opioid dependence. Additional pharmacotherapy may include mood stabilizers like lithium or valproic acid to prevent mood episodes, and antipsychotics such as risperidone or olanzapine to control residual psychotic symptoms. Antidepressants could be considered if depressive symptoms emerge, although her current mood stability suggests caution to avoid triggering manic episodes.

Ongoing outpatient psychiatric follow-up is vital, with the patient scheduled to see her psychiatrist in 1-2 weeks to monitor medication efficacy and side effects. Weekly psychotherapy sessions can provide psychoeducation and support, enhancing medication adherence and coping skills. Safety considerations are paramount; at present, she demonstrates low risk for violence or self-harm but requires ongoing assessment, especially given the substance use context.

Implications of Dual Diagnosis

Patients with co-occurring mental health and substance use disorders face complex challenges that require integrated treatment models. The intersectionality of schizoaffective disorder and opioid dependence necessitates careful coordination among mental health, addiction specialists, and primary care providers. Evidence supports integrated approaches that combine pharmacotherapy with psychotherapy, case management, and social support services to improve long-term outcomes (Maremmani et al., 2022).

The Role of the Nurse Educator

The nurse educator plays a pivotal role in preparing nurses for the complexities of psychiatric care, particularly within the evolving landscape of mental health treatment. As per the College of Collegiate Nursing Education (CCNE) standards and recommendations, doctoral-prepared nurses should acquire foundational knowledge in behavioral health, curriculum development, and evidence-based practice. Courses such as Advanced Pathophysiology, Psychopharmacology, Mental Health Assessment, and Health Policy are essential to equip nurse educators with the necessary competencies. These courses foster a nuanced understanding of psychiatric illnesses, medication management, and ethical considerations, enabling nurses to educate future practitioners effectively.

The Doctor of Nursing Practice (DNP) program offers rich resources, including simulation labs, evidence-based curriculum development tools, and interprofessional education modules, designed to enhance teaching skills. These resources support the nurse educator in designing comprehensive training programs, mentoring students, and translating research into practice (Wang et al., 2021). Such competencies are critical in advancing mental health care, reducing stigma, and improving patient outcomes across diverse settings.

Conclusion

In sum, thorough psychiatric assessment, including detailed subjective and objective data collection, is vital to diagnosing and managing complex cases such as DB’s. An integrated treatment approach combining medication, psychotherapy, and coordinated care can optimize her functional status and stability. Furthermore, empowering nurse educators through targeted coursework and DNP resources is fundamental in preparing future nurses to meet the challenges of mental health care delivery, ensuring high-quality, evidence-based practice that addresses the needs of individuals with dual diagnoses.

References

• Martinotti, G., Chiappini, S., Mosca, A., Miuli, A., Santovito, M. C., Pettorruso, M., & Giannantonio, M. D. (2022). Atypical antipsychotic drugs in dual disorders: current evidence for clinical practice. Current Pharmaceutical Design, 28(27), 4321-4334.
• Wang, J., Chen, Y., & Lee, S. (2021). Enhancing nursing education with simulation and evidence-based curricula. Journal of Nursing Education and Practice, 11(4), 45-52.
• Maremmani, I., Ricci, V., & Timpano, M. (2022). Integrated treatment of dual disorders: evidence and clinical implications. Frontiers in Psychiatry, 13, 894. https://doi.org/10.3389/fpsyt.2022.894350
• Noel, J. M., & Jackson, C. W. (2020). ASHP therapeutic position statement on the use of antipsychotic medications in the treatment of adults with schizophrenia and schizoaffective disorder. American Journal of Health-System Pharmacy, 77(24), 2040-2048.
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2014). Mental health of young people: A global public-health challenge. The Lancet, 379(9833), 1673-1683.
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Behavioral health treatment services locator.
• World Health Organization. (2019). Mental health: Strengthening our response. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
• Gask, L., & Bak, M. (2018). Principles of mental health nursing: A holistic approach. Nursing Standard, 33(30), 50-56.
• Wang, S., & Wu, L. (2021). Innovations in nursing education: Simulation and technology integration. International Journal of Nursing Education Scholarship, 18(1), 1-9.