Week 5 MSUD Training Note and Reflection
Complete Modules 1-3 of the American Psychiatric Nurses Association’s MSUD: Medications for Substance and Opioid Use Disorders.
Copy and paste: https://e-learning.apna.org/products/msud-medications-for-substance-and-opioid-use-disorders-2023
Then submit a progress note and answer reflection questions based on the information presented in Modules 1-3 of the MSUD training.
Reflection questions:
Psychiatric Note Format
Demographic data: Do not include identifying information. Must be HIPAA compliant.
Chief complaint:
History of present illness:
Current working diagnoses:
Current psychiatric medications:
Non-psychiatric medications:
Allergies:
Review of Systems: As appropriate, listed by body systems in bullet form
Mental Status Exam:
Physical Exam: Physical exams should be appropriate for the patient and your clinical setting. For example: a telehealth follow up for MDD versus an inpatient psychiatric unit for acute psychosis will have different physical exams.
VS: If obtained
Results: If applicable and results obtained
PHQ9: HAM-A
Labs:
Impression: Narrative discussion of current status and symptoms, how the patient is tolerating the current treatment and any progress toward goals. Also discuss any change in diagnoses or changes to the plan and the reason why. Always discuss the safety evaluation and current safety plan.
Plan:
Medication orders
Psychotherapy orders to begin or continue
Safety orders
Non-pharmacologic orders – labs, psychoeducation, referrals
Follow up
Signature: Current credentials, PMHNP student
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