NURS6248 George Washington University Week 10 Nursing Questions Use the Evaluation and Management Service Guide to answer the questions and correctly code
NURS6248 George Washington University Week 10 Nursing Questions Use the Evaluation and Management Service Guide to answer the questions and correctly code the following 2 vignettes. When responding to a peer explain one or two items that could be added or removed to/from the service to change the level of service and what code would then be used. Instructions: Click the link above to go to the discussion forum and participate in this week’s discussion.
This week you will assume the role of a clinical expert and analyze a malpractice claim against a fellow
PMHNP. You have been selected to sit on a malpractice panel with 2 other experts, both psychiatrists.
Read the case carefully and render a judgment for or against malpractice. In your response you must: 1)
identify the legal and ethical issues under consideration (e.g., negligent prescribing, split treatment,
informed consent, etc.), and 2) provide a strong rationale that includes a discussion of the key elements
of a malpractice claim (i.e., duty, deviation, damage, and direct causation) for why you support or do not
support a claim of malpractice; and for why you support or do not support the claim for malpractice.
CASE
Patient:
42-year-old Caucasian male
Never married; no children; high-school graduate; employed on and off as a janitor; only
next of kin is older sister; parents deceased; recently relocated to be near his sister; lives
alone in a basement apartment
History of diabetes mellitus, emphysema, and pancreatitis.
Diagnosed with Schizophrenia and Alcohol Use Disorder at the age of 23.
2 inpatient hospitalizations (1 long-term care for alcohol use disorder and 1 for
stabilization of medication following a psychotic episode; last hospitalization
approximately 5 years ago)
Patients medical care was managed by a PCP where a patient used to live; has established
care with a local PCP
Was receiving care from a psychiatrist for medication management; has not been seen for 3
months.
Provider:
PMHNP with 5 years of experience
Employed at a private practice and maintains a collaborative practice agreement with a
psychiatrist
First malpractice suit
Initial visit with PMHNP:
Assessment
Completed a comprehensive psychiatric evaluation
Established diagnosis of schizophrenia and alcohol use disorder
Current medications: Prozac 40 mg 1 tablet bid; Lithium 300 mg tid; Risperdal 4 mg (1.5
tabs in am and 1 tab at HS); Klonopin 2 mg tid;
Metformin, Zantac, Vitamin D, Robaxin, and Prilosec (doses unknown).
Past trials of Seroquel, Zoloft, Ativan, Wellbutrin, and Depakote (response unknown)
No active psychosis; denies SI/HI
Mental status: unremarkable
Smokes 1.5 ppd; sober for 2.5 years; denies illicit drug use
Plan
Obtained ROIs to for past medical records from the psychiatrist and to talk with current
PCP
Obtained baseline labs including BMP, A1C, and Thyroid.
Decrease Klonopin 2 mg bid; discontinued Risperdal
* PMHNP documents that medical education was completed and patient verbalized
understanding
Follow-up visit #1 approximately 1 month later:
Status unchanged with exception of patient reporting an increase in paranoia and
occasionally hearing things in the walls of his apartment.
PMHNP has not received past records or spoken with PCP
Baseline labs WNL
Plan
Maintain current meds
Add Saphris 10 mg bid
Follow-up in 2 months
Follow-up visit #2 approximately 2 months later:
Continues to ? AH and anxiety
States he doesnt feel as good as he use to when he took Seroquel
PMHNP has not received past records or spoken with PCP
Plan
Maintain current medications
Add Seroquel and titrate to 400 mg/day
Follow-up in 1 month
* PMHNP documents that medical education was completed and patient verbalized
understanding
Three days after follow-up visit #2:
Sister reports she visited the patient in the morning and he was lethargic and had difficulty maintaining
balance; patient told sister he had been taking all his medications, including Seroquel.
Four days after follow-up visit #2:
Sister finds the patient unresponsive and calls 911. Patient dies upon arrival at the hospital. Cause of
death: Myocardial ischemia resulting in asystole
1 year later:
Sister files the malpractice claim against PMHNP. Claims that patient was taken off Seroquel by the
previous psychiatrist because it caused his diabetes. States that Seroquel caused his death and that
PMHNP did not review his past medical records or consult with PCP.
Instructions: Click the link above to go to the discussion forum and participate in this week’s discussion.
Use the Evaluation and Management Service Guide to answer the questions and correctly code the following 2
vignettes. When responding to a peer explain one or two items that could be added or removed to/from the
service to change the level of service and what code would then be used.
Vignette #1
Einstein, Albert DOB: 03.14.1879 Date of Visit: 11/11/12
Start:1:45p Stop:2:30p Total face to face time: 45 min
CPT: 90836, E/M ?????
CC: F/U for Anxiety
Interval Hx: The patient c/o worsening anxiety x 1 week with panic symptoms that occur intermittently, on
average once per day, last for 5 minutes, and are brought on unexpectedly by unclear precipitants, in the
context of his upcoming dissertation defense.
ROS: Pt. reports intermittent panic symptoms, including GI upset, SOB, and dissociative feelings.
PFSH: Patient is a graduate student in Physics.
PME:
Speech-normal rate, rhythm, volume, speaks English with an accent
Thought Processes-coherent
Judgement-good
Fund of Knowledge-excellent
Affect-anxious
General Appearance-messy hair, not wearing socks, otherwise well-groomed.
Dx: Anxiety NOS 300.00
Current Meds: Zoloft 100mg qd.
Side effects: No side effects or adverse reactions noted or reported.
Allergies: NKDA
Labs: ordered-none, reviewed-none
Psychotherapy Note: Discussed with patient his automatic thoughts, and the specific concerns he has about his
dissertation defense. Reviewed relaxation techniques with the patient.
Plan:
Continue current medication
f/u 1/week psychotherapy
1. What was the level of history taken? (Problem focused, Expanded Problem-focused or
Detailed or Comprehensive)
2. How many bullet points identified in the examination?
3. What was the level of decision making (Straightforward, Low Complexity, Moderate
Complexity, High Complexity)?
4. What was the level of risk (Minimal, Low, Moderate, High)?
5. What CPT code would you use to bill for this patient (99212, 99213, 99214, 99215)?
Vignette #2
HPI: Patient is a 59-year-old divorced male with a history of depression (recurrent) and alcohol dependence.
Patient has been drinking continuously on a daily basis for 5 years. The patient is still having nightmares at
least twice a week but the prazosin has helped reduce the number of nightmares but is causing him to feel
dizzy. He still has feelings of loss and worthlessness.
ROS: Patient denies shortness of breath or chest pain. Positive for headaches that come on suddenly at least
twice a week. No known drug allergies. Positive for major depression and all other systems
reviewed negatively.
PFSH:
Past medical history- current meds Valium 4mg BID, Nexium 20mg daily, Prazosin 2mg daily, Prozac 80mg
daily
Social history – Married 27 years then divorced 4 years ago. The daughter died 2 months ago, son in college,
patient lives alone.
Exam:
1.
2.
3.
4.
5.
Constitutional – General appearance Appears stated age. Dirty clothes, poor hygiene, poor
eye contact.
Attention span concentration- Cooperative and attentive throughout a session
Description of thought process- Organized, reality-based, focused on daughters death
Mood affect – reports depressed mood, affect anxious
Abnormal thoughts-Denies psychosis, Denies any thoughts of harming others, has passive
thoughts of not wanting to live but denies intent or plan of self-harm
Judgment – poor – drinking despite knowledge of how it affects his depression and upsets
his son
Assessment: Confirmed diagnosis of Major Depressive Disorder, recurrent, moderate and Alcohol use
disorder. Recommended patient join dual diagnosis group every Tuesday. Continue current meds. Follow up
one month, call sooner if needed.
What was the level of history taken (Problem focused, Expanded Problem-focused, Detailed or
Comprehensive)?
How many bullet points identified in the examination?
What was the level of decision making (Straightforward, Low Complexity, Moderate Complexity,
High Complexity)?
What was the level of risk (Minimal, Low, Moderate, High)?
What CPT code would you use to bill for this patient (99212, 99213, 99214, 99215)?
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