diagnosis and treatment plans|My homework helper

Posted: February 20th, 2023

Directions:

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 HIPPA laws when writing these letters.

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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

 

 

SOLUTION

Dear Primary Care Provider,

I am writing to thank you for referring your patient, Ms. A, to me for a psychiatric evaluation. I had the opportunity to meet with her on several occasions and would like to provide you with an update on her status.

Upon evaluation, Ms. A presented with symptoms consistent with a major depressive disorder. She reported a lack of interest in daily activities, feelings of hopelessness and worthlessness, and sleep disturbances. Additionally, she expressed anxiety symptoms such as worry, restlessness, and trouble concentrating. After conducting a comprehensive evaluation, I confirmed the diagnosis of major depressive disorder and recommended a treatment plan that includes psychotherapy and antidepressant medication.

Ms. A has been compliant with her treatment and has shown a significant improvement in her symptoms. She has reported feeling more motivated, enjoying daily activities, and experiencing improved sleep patterns. She continues to engage in weekly psychotherapy sessions, and her medication has been adjusted to her response to treatment.

In conclusion, I would like to thank you for entrusting me with the care of your patient, Ms. A. I will continue to keep you updated on her progress and welcome any further inquiries you may have.

Sincerely,

[Your Name and Credentials]

Dear School/Employer,

I am writing on behalf of my patient, Mr. B, regarding his need for special accommodations in the workplace/school setting. Mr. B has been under my care for the past several months and has been diagnosed with attention deficit hyperactivity disorder (ADHD). This condition has caused him significant difficulty in managing his daily responsibilities.

Mr. B has reported experiencing difficulty with time management, organization, and focus, which has resulted in missed deadlines and poor academic/work performance. To address these concerns, I have recommended several accommodations that I believe will assist him in achieving success in his academic/work environment.

These accommodations include extended time for testing/assignments, preferential seating, access to a quiet study area, and frequent check-ins with his supervisor/teacher. Additionally, I have recommended that he receive additional support in the form of a tutor or mentor to assist him

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