Sample Patient Report

Ms. Smith reported severe sexual abuse by her biological father, between the ages 6-12. She attempted to advise her

Patient lives with her husband of 10 years and 3 children in Denver, Colorado. Patient denies any spousal abuse. She also denies smoking, alcohol, or drug use during her pregnancy. Patient completed middle school, and currently works as a house wife. Patient is of low economic status.

31 y/o AA male patient seen today for psychiatric-mental health assessment. He is awake, alert and oriented x4. He is calm, cooperative and follows commands during assessment. The patient reports he is depressed, difficulty sleeping and nightmares at night. The patient explained his depression is as a result of deep thinking from a news he received two days ago from his elder brother that his mother is ill. Stressors identified by the patient include losing his job a week ago before the news about his mother; his wife is 6-months pregnant with their first child, who currently works part-time at her present job; patient relates difficulty paying monthly bills and inability to provide adequately for his family as a man. The patient denies mood swings, suicidal/homicidal thoughts and ideation. Patient reports his spouse is at work at the moment and he does not want to put stress on his wife due to her current condition. Patient denies been hospitalized for depression or psychiatric illness; and denies family history of mental illness. Patient reports he is seeking help because he does not like feeling this way using terms of “helpless and loss of worth from his spouse”. Patient reports he needs help with his depression and nightmares before his current condition get out of hands and ruined his marriage.

Present Psychiatric Illness/Symptoms: Client reports episodes of feeling completely depressed to the point of having suicidal thoughts, difficulty focusing on set tasks at work, having emotional breakdowns during lunch breaks at work, and stabilizing moods. Has not attempted suicide in a year, but still thinks about it.

Rationale: Jennifer has been presenting with symptoms for unspecified amount of time. Jennifer meets six of the criteria for symptoms being present during the same 2-week period and represents a change from previous functioning. Jennifer is depressed most of the day, nearly every day, has diminished interest in all or almost all activities most of the days, nearly every day, has fatigue or loss of energy nearly every day, feelings of worthlessness, and diminished ability to think or concentrate, is having recurrent thoughts of death, recurrent suicidal ideation without a specific plan. The symptoms have cause clinically significant distress or impairment in social, occupational, and other functioning areas. There is no know substance or medical condition and occurrence is not better explained by Schizophrenia Spectrum or Psychotic Disorders. Jennifer has never had a manic episode or a hypomanic episode. Possible family history of depression - mother.

Sara is in need of residential treatment due to her history of self-injurious behaviors, and multiple attempts of suicidal gestures. Sara requires a higher level of care which outpatient care is currently failing to provide her at this time. Sara continues to have depressive symptoms and anxious feelings for the last few months. The patient has had two acute inpatient admissions within the last 3 months and requires long term stabilization. At this time Sara requires 24 hour supervision and ongoing intervention and treatment.

 of major depression is supported by DSM-IV criteria. I have no reason to suspect that her symptoms are caused by a mood disorder like bipolar because she exhibits no manic episodes, nor has she ever.

The client that I have chosen is a woman named Rhonda. Rhonda is a mother of two children, who is experiencing some difficulties in her life. Rhonda is a 32 year old woman who has a long-term history of depression and alcoholism. She has been suffering from depression ever since she was 13 years old. Rhonda also has been suffering from post-partum depression after the birth of her children.

Patient is a 46 year old female who presented to the ED via EMS due to overdose on Benadryl. Patient reports financial issues with supporting her daughter going to college. Patient reports depressive symptoms of fatigue,worthlessness, hopelessness, tearfulness,irritable, and anhedonia. At the time of assessment, patient denies feeling suicidal or having a plan. While patient currently denies suicidal ideation and plan, review of the patient's medical documentation does not support that. When confronted about admitting being suicidal and having a plan, the patient presented guarded and later reports she felt like harming herself during overdose due to financial situation.The patient reports she does not want to let any of her daughters down.

The offender is in clinic today for her first visit. She says her right eye has been red and sore for about 24 hours. She has had some watery drainage from her eye as well and she has been rubbing it. She is not sure if she feels like there is something in her eye or not. She denies any trauma. She has had some nasal congestion with her eye situation but she has not had an upper respiratory infection exactly. She has not had any fevers, aches, or chills and she has no history of eye diseases. She came to the facility on 06/20, she had been in the Scott County Jail where she was diagnosed with chlamydia and started on doxycycline which she took for four days. While she has been here, she has had the medication ordered but she has not been taking it, so she has partially treated chlamydia. She also says that she has multiple skin lesions from injecting drugs and her boyfriend has hep C.

Molly is a 29-year-old woman unemployed, living with her parents. She presents to the therapist looking sad, stark and exhausted with lethargic movements. She expresses concerns with feeling down for 2 ½ years after a job loss from an exciting IT career. She is unmarried and currently using marijuana regularly and moderate amounts of alcohol to cope with her sadness. She can no longer find pleasure in things, her mood can be described as depressed, and she has poor sleep hygiene, difficulties with concentration, no appetite, and no interest in sex. She also has concerns about feeling irritable and nervous. She has recently unintentionally lost 15lbs. While talking with the therapist she frequently is tearful. This is her first experience with a

My vision for this practicum project stemmed from recent reports of soaring readmission rates for Vanguard Hospital core measure patients; which include patients with a diagnosis of a myocardial infarction, congestive heart failure, and pneumonia. Preventing unnecessary readmissions for core measure patients was the topic of discussion at the monthly staff meeting that I attended. The Director of Nursing and Quality Improvement Coordinator led the discussion; which included, informing the staff of recent Medicare and Medicaid reimbursement cuts related to the increase in readmissions for these particular patients. In addition, statistical information was displayed using SHP data and the Midas Report, revealing how Vanguard Hospital and Home

We acknowledge receipt of the Appointment of Personal Representative and Authorization for Release of Health Information for Visiting Angels. Please be advised that the Healthcare Practitioner Statement completed by your daughter as your physician is not acceptable under your LTC-400 policy language. Your LTC-400 specifically defines a Physician as “A doctor of medicine who is duly licensed to practice in the state where services are provided. The Physician must not be you or a Family Member”. Also, the definition of Family Member is “Your spouse, or the parent, child, brother or sister of you or your spouse”.

Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking

Social History: The patient widowed and lives in a house with her two daughters. Currently employed as a supervisor at Walmart and has health insurance through her work. Works full time and enjoy her work. She enjoys spending time with her family. She is sexually active. She is currently in an intimate relationship for the past one year after the death of her husband and used condoms occasionally when having sex. Highest level of education is bachelor’s degree