PCN-485 Topic 1 Standard Abbreviations Worksheet (Obj. 1.3) Assignment

 

Complete the Standard Abbreviations Worksheet.

PCN-485 Standard Abbreviations Worksheet

Directions:  Edit the following clinical note using standard abbreviations where applicable.  Use the “Standard Abbreviations for Counselors” resource to guide you through completion of the worksheet.

Clinical Note:

Today, Joe came into the office for his regularly scheduled counseling appointment.  Today’s visit was to review his assessment by the resident psychiatrist to explore what his diagnosis was.  The psychiatrist used the Diagnostic and Statistical Manual of Mental Disorders-5th Edition to review the symptoms Joe was experiencing.  Since Joe was arrested three weeks ago for driving under the influence, it was determined that he could be suffering from substance use issues. Client reports he is not currently on any medication, but is complaining of symptoms of depression and anxiety, as well as craving a drink.

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After obtaining a release of information from his probation officer, it was learned that Joe is facing charges of driving under the influence, and has a prior history of this behavior.  He has been arrested twice before.  In his most recent stay in jail, he was talking about how depressed he was, and the jail called the counselor.  That counselor referred Joe to the psychiatrist. Joe disclosed that on a recent trip to the emergency room, after he had a panic attack, he decided that it was time for a change. At first, he thought his blood pressure was too high and he was having a heart attack.  Against medical advice, Joe left the emergency room without receiving any medication for his anxiety.  He left with his brother and decided to call the psychiatrist.

After reviewing the diagnosis made by the psychiatrist, and explaining the purposes of the Diagnostic and Statistical Manual of Mental Disorders-5th Revision, Joe decided to schedule another appointment to obtain a mental status exam, as well as schedule a treatment planning session. 

Sarah Smith, , LPC                                                              October 29, 2013

Case Manager Signature                                                                Date

 

 

Course: PCN-485 Advanced Case Management for Addiction and Substance Use Disorders
School: Grand Canyon University

  • 04/02/2020
  • 40
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