Case Vignette—Joshua Presenting Situation Joshua is a 12 year old boy who attends Middle School as a 6th grader. Joshua has been in placement with h

CASE STUDY:

Case Vignette—Joshua Presenting Situation Joshua is a 12 year old boy who attends Middle School as a 6th grader. Joshua has been in placement with his grandmother for several months. His behavior has been on the decline since his middle sibling was recently placed in the home with him. He was strongly reactive to any signs that his sister was receiving more attention than he was. He becomes easily angered, his moods shift from constricted to volatile, with frequent angry outbursts, that carryover to and interfere with school. Joshua shows multiple signs of arousal (e.g., difficulty sleeping, impaired concentration, edginess and irritability). He was recently diagnosed with oppositional defiant disorder and ADHD although he doesn’t yet have an IEP. In school, he is taking the following classes: Remedial Reading, Math, 6th grade Science, Art, Social Studies and P.E. His favorite class is Art and the Remedial Reading class is his least favorite. He is at least two years behind in reading. When he is in a happy mood, Joshua is talkative and social with his peers. Joshua’s grandmother, who has her own history of childhood trauma, has become more depressed and overwhelmed by his emotional outbursts and she has had difficulty providing consistent caretaking to either of the children, including sending them to school. She is reluctant to make contact with the school as it just adds one more overwhelming responsibility to her life. Trauma History Joshua has been in the care of his Grandmother since he was 18 months old at which time Child Protective Services removed him from his parents’ care due to neglect, physical abuse and parental substance abuse. When initially interviewed by CPS the mother acknowledged that she was under tremendous stress due to an often violent relationship with her husband. She admitted that caring for Joshua was difficult because he was often irritable and rejecting of her attempts to console him. At other times, he was very restless and clingy toward the mother, especially when the father was present. She also said Joshua was “slow to develop.” The mother admitted that she and her husband had a history of drug and alcohol abuse. At age 5, an attempt to reunify Joshua with his parents failed when he was once again removed from their care due to a report made by his Kindergarten of seeing bruises on Joshua’s legs and arms. He was placed back in care with his grandmother and has been with her since. His parents have separated and he only sees his mother at family events and holidays. He has had no contact with his father since the second set of allegations was substantiated when he was 5

TEMPLATE

Patient Name: XXX
MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints

O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)
Differential Diagnoses:
1. choose 3 differential diagnoses
2.
3.
Definitive Diagnosis:
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time

GRADING RUBRIC:

Assignment Criteria Level III Level II Level I Not Present
Criteria 1 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Subjective Information
● Complete and concise summary of pertinent information. ● Well organized; partial but accurate summary of pertinent information (>80%). ● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided. ● Does not meet the criteria
Assignment Criteria Level III Level II Level I Not Present
Criteria 2 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Objective Information
● Complete and concise summary of pertinent information. ● Partial but accurate summary of pertinent information (>80%). ● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided. ● Does not meet the criteria
Assignment Criteria Level III Level II Level I Not Present
Criteria 3 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Assessment: Problem Identification and Prioritization ● Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

● Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). ● Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. ● Does not meet the criteria
Criteria 4 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Assessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem ● An optimal and thorough assessment is present for each problem ● An assessment is present for each problem listed but not optimal ● Assessment is present for 50-80% of problems ● Does not meet the criteria

Assignment Criteria Level III Level II Level I Not Present
Criteria 5 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Assessment: Treatment Goals ● Appropriate and relevant therapeutic goals for each identified problem. ● Appropriate therapeutic goals for most identified problems (>80%). ● Appropriate therapeutic goals for a few identified problems (50%-80%). ● Less than 50% of problems have appropriate therapeutic goals.
Assignment Criteria Level III Level II Level I Not Present
Criteria 6 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Plan: Treatment Plan ● Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included. ● Includes most of the requirements for each identified problem (>80%). ● Incomplete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided. ● Less than 50% of problems have an appropriate and complete treatment plan.
Criteria 7 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Plan: Counseling, Referral, Monitoring & Follow-up ● Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. ● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems. ● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%). ● Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
Maximum Total Points 50 40 30
Minimum Total Points 41 points minimum 31 points minimum 1 point minimum

Updated 3/2/2023