Unit 2Weekly Clinical Communication and Documentation Requirements. 600w. 3 references. Due 11-11-22



Clinical Decision-Making NU671

Unit 2Weekly Clinical Communication and Documentation Requirements. 600w. 3 references. Due 11-11-22

For this assignment the focus is a 50y/o male patient. construction worker. Came in for follow up after a 2024 ICD-10-CM Diagnosis Code M75. 102: Unspecified rotator cuff tear or rupture of left shoulder, not specified as traumatic. The injury occurred 1 month prior. The patient has not returned to work since his injury and is suffering from chronic pain, anxiety and depression related to his financial obligations at home. Patient is the head of his household; his wife does not work. He came in for a follow-up with his primary care provider. His blood pressure was also elevated due his stress. He was placed on fluoxetine (Prozac) 20 milligrams (mg) once a day in the morning and Carvedilol 6.25 milligrams (mg) 2 times a day. Over the counter Tylenol and ibuprofen recommended for pain. Patient education was provided regarding medication management and stress management.

1. Clinical Highlights.

· On your journey to become a psychiatric mental health nurse practitioner discuss a patient encounter that was particularly interesting and what you learned from it?

· Identify a personal learning need you discovered while assessing or managing a specific diagnosis. What steps will you take to improve your understanding or skills?

2. Looking Ahead

· What clinical goal would you like to tackle next week?

· What is your proposed clinical schedule (date/time/total hours) for next week?

Old assignment-paper
This is the assignment that was completed previous semester. I am retaking this class. The assignments are the same but I cannot submit the same work, the instructor runs all papers through the plagiarism checker. Please redo this assignment so I can resubmit it the content will be the same. Thanks

Unit 3 Weekly Clinical Preceptee Communication And Documentation


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Unit 3 Weekly Clinical Preceptee Communication And Documentation

Clinical Highlights

I had a patient interaction that was especially intriguing and taught me essential lessons throughout my training to become a psychiatric mental health nurse practitioner. A session was held with a young adult experiencing acute anxiety and depression. The patient's background of childhood trauma had a significant effect on how she felt mentally. It was challenging to develop a therapeutic connection with her when we first started our session because she looked reserved and guarded. I eventually won her trust through attentive listening and compassionate conversation. I discovered the extent of the patient's emotional suffering as she opened up and the survival skills she had developed. The experience showed me the value of being persistent and patient while establishing a connection with people who have undergone trauma. It reaffirmed how crucial it is to give people a secure, judgment-free area to express their emotions.

The incident also highlighted the challenges of treating coexisting mental health disorders. Her depression and anxiety were linked and exacerbated each other, which posed special difficulties in creating an all-encompassing treatment strategy. I saw the significance of providing mental health treatment using a holistic approach that considers all facets of a patient's life, particularly their social network, way of life, and coping mechanisms.

Personal Learning Need

I discovered a personal learning needs for treating individuals with personality disorders throughout my evaluations and management of various conditions. I found that there was room for development in the areas of understanding and treating borderline personality disorder (BPD). I felt the need to improve my knowledge and abilities since BPD is a complicated and sometimes misunderstood disorder. Acquiring evidence-based clinical knowledge is important in ensuring that people with BPD have better treatment (Iliakis et al., 2019). I have various actions I want to take to increase my knowledge about and management abilities for BPD. I will first do an in-depth study and analyze recent BPD literature to understand the underlying causes, symptoms, and evidence-based treatment options for BPD. This study will help me stay current on the most recent developments and suggestions for treating personality disorders.

I intend to seek mentoring or supervision from seasoned mental health practitioners knowledgeable about treating people with personality problems. Mentoring often provides mental health practitioners with insightful advice that will make them handle challenging situations easier (Zajac et al., 2021). I will look for chances for continuing education relevant to BPD and similar personality disorders. I will be able to communicate with professionals, gain knowledge from practical examples, and have conversations with others with similar learning interests by participating in these educational activities. Ultimately, I want to use my clinical rotations to put my newfound understanding of BPD and its treatment into practice. I may use evidence-based therapies and assess their efficacy while getting feedback from seasoned preceptors by actively interacting with BPD patients.

Looking Ahead

My clinical objective for the coming week is to improve my capacity for performing thorough mental health evaluations. A comprehensive assessment is crucial to psychological mental health practice since it is the basis for a precise diagnosis and efficient treatment planning (Maruish, 2019). The following is the proposed clinical schedule for next week.




Shadow an experienced psychiatric mental health nurse practitioner during patient assessments in the morning. In the afternoon, review assessment tools and protocols.


Conduct mental health assessments under the supervision of a preceptor, focusing on gathering patient history, current symptoms, and potential risk factors.


Attend a workshop on the importance of cultural competence in mental health assessments, exploring techniques for conducting culturally sensitive interviews.


Discuss assessment findings with preceptors, receive feedback, and participate in case discussions with fellow students to learn from their experiences.


Engage in self-directed study, reviewing assessment guidelines and practicing documentation skills to ensure accurate and thorough recording of patient information.

I intend to spend 30 hours on clinical work, education, and independent study during the week. I plan to considerably enhance my assessment abilities as a psychiatric mental health nurse practitioner by devoting time and effort to this clinical objective and offering better treatment to my future patients.


Iliakis, E. A., Sonley, A. K., Ilagan, G. S., & Choi-Kain, L. W. (2019). Treatment of borderline personality disorder: is supply adequate to meet public health needs?.
Psychiatric Services,
70(9), 772-781.

Maruish, M. E. (2019).
Essentials of treatment planning. John Wiley & Sons.

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance.
Frontiers in Communication,
6, 606445.