Clinical Packet Mental Health .docx - Name Date Course Name/Number Clin ical Pac ket Unit Focus STUDENT/COURSE Chris Carman DEMOGRAPHICS Patient’s Age

Clinical Packet Mental Health .docx - Name Date Course...

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Name: __________________________________________ Date: ___________________ Course Name/Number: _________________________________________________ Clin ical Pac ket Unit Focus _________ _______
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STUDENT/COURSE: Chris Carman DEMOGRAPHICS: Patient’s Age: 19 Patient’s Gender: Male Date of this Admission: ___________________________ HT: _____________ in. WT: ____________ lb. / kg Allergies: NKDA Other _______________________________________________________________________________________ Psychosocial and Environmental Problems: [] Primary support group: [] Social environment: [] Educational: [] Occupational: [] Housing: [] Economic: [] Access to health care services: [X] Interaction with the legal system/crime Mental Health Diagnosis: Alcohol abuse – no other past mental health issues ___________________________________________________________________________________________________________________________ Brief Admission History (What led up to your patient needing psychiatric hospitalization?): Patient self-admitted themselves after leaving the scene of an accident. Patient states he was driving home drunk and drove his car off the side of the road/pier and into the water. Describe any Family History of Psychiatric Issues if available: Unknown Describe any Substance Abuse History if available: Patient states he has a history of drinking alcohol. States it’s worse when he and is girlfriend get into an argument. States he drinks when he feels upset or down. Describe any Trauma Abuse History if available: (Domestic Violence, sexual or physical abuse, etc.) Denies any past history of abuse. Does state he was a foster child and was later adopted by his now parents. States he has good family support. STUDENT/COURSE: _______________________________________________________________________________ CURRENT PSYCHIATRIC MEDICATIONS Medication Dosage / Route Reason for Nursing Side Effects
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Name (Generic & Name Brand) / Frequency Medication (may be off-label use) Considerations / Interventions Patient is not taking any medication STUDENT/COURSE: Chris Carman MENTAL STATUS EXAMINATION (MSE) ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA
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