Review 1 de-identified intake note for a patient with either ADHD or bipolar. Please ensure your note includes the following:
Chief Complaint
HPI
Risk Assessment
Medical & Substance History
Mental Status Exam
Treatment/Diagnosis
Clinical quality is extremely important . One way we assess clinical quality is to review a sample of clinical notes to gain insight into your clinical thought process and billing/coding practices. You are free to create an initial note in your typical template rather than sharing redacted patient notes if preferred.
Sample solution
Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell.
In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.
God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.
Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.
To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.
References
Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.
Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.
Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.
Sample Answer
Sample Answer
De-Identified Intake Note
Patient ID: 001234
Date: [Insert Date]
Clinician: [Insert Clinician Name]
Facility: [Insert Facility Name]
Chief Complaint
The patient presents with difficulties in attention and mood regulation, expressing concern about their inability to focus on tasks and frequent mood swings.
HPI (History of Present Illness)
The patient is a 12-year-old male who has been experiencing symptoms consistent with Attention Deficit Hyperactivity Disorder (ADHD) and mood instability for the past year. According to the mother, he has significant trouble concentrating in school, often daydreaming during lessons, and struggles to complete homework assignments. His grades have dropped from A’s to C’s over the last two semesters. The mother reports that the patient often seems restless and fidgets excessively, which affects his ability to sit still during classes.
In terms of mood, the patient experiences rapid mood swings, transitioning from irritability and anger to periods of sadness. These shifts can occur several times a day and are often triggered by school-related stressors or conflicts with peers. The mother notes that he has had episodes of emotional outbursts, where he becomes verbally aggressive, particularly when asked to complete tasks he finds boring. There is no reported history of suicidal ideation or self-harm.
The patient has no previous psychiatric treatment history and has never been on medication for these issues. Family history reveals that his father has a history of ADHD and his maternal uncle has been diagnosed with bipolar disorder.
Risk Assessment
– Suicidal Ideation: Denies any thoughts of self-harm or suicide.
– Homicidal Ideation: Denies any thoughts of harming others.
– Substance Use: Denies use of alcohol, cannabis, or other drugs.
– Safety Concerns: No current safety concerns reported; however, the patient exhibits impulsive behavior that requires monitoring.
Medical History
– Chronic Conditions: None reported.
– Medications: None.
– Allergies: No known drug allergies (NKDA).
Substance History
– Alcohol Use: Denies.
– Tobacco Use: Denies.
– Recreational Drugs: Denies.
Mental Status Exam
– Appearance: Well-groomed, appropriate attire for age.
– Behavior: Cooperative but appears restless throughout the session.
– Speech: Normal rate and tone; occasionally tangential.
– Mood/Affect: Mood described as “frustrated”; affect is labile, shifting from frustration to sadness.
– Thought Process: Logical but occasionally distracted; difficulty maintaining focus on questions.
– Thought Content: No delusions or hallucinations; denies suicidal/homicidal ideation.
– Cognition: Alert and oriented to person, place, time; able to recall recent events but struggles with attention and concentration.
– Insight/Judgment: Limited insight into behavioral issues; judgment appears intact regarding personal safety.
Treatment/Diagnosis
Diagnosis:
1. Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation (F90.2)
2. Mood Disorder Not Otherwise Specified (NOS) (F39) – pending further evaluation.
Treatment Plan:
1. Referral for psychological testing to confirm ADHD diagnosis and assess for possible mood disorder.
2. Educate the patient and family regarding ADHD, including strategies for managing symptoms.
3. Discuss the possibility of starting a trial of a stimulant medication if ADHD is confirmed.
4. Recommend behavioral therapy focusing on coping strategies for emotional regulation and attention management.
5. Schedule a follow-up appointment in 4 weeks to reassess symptoms and response to any interventions initiated.
Signature:
[Clinician Name], [Clinician Credentials]
[Date]
This note reflects the necessary components for a comprehensive intake assessment while ensuring clinical quality through thorough documentation of the patient’s presenting issues, history, and mental status exam.
