N2

Depression stable on treatment

Skilled psychiatric assessment completed for a patient with depression on treatment. The PHQ-9 is improved and stable at a low level from a higher baseline, mood and engagement have improved, and the patient denies thoughts of self-harm on direct screen; the antidepressant is taken as prescribed and tolerated. Findings indicate stable, treated depression. RN-level assessment was required to monitor treatment response with a validated tool, screen for risk, and evaluate adherence and side effects. Adherence, the coping plan, and crisis resources reinforced; teach-back accurate. Continued skilled monitoring indicated.

N3

Anxiety managed with coping strategies

Skilled psychiatric assessment completed. The GAD-7 is at a low, manageable level and the patient reports that learned coping strategies and the prescribed treatment keep anxiety controlled; mood is at baseline and there is no risk on screen. Findings indicate managed anxiety. RN-level assessment was required to screen anxiety and mood with validated tools, screen for risk, and evaluate the coping and treatment plan. Coping strategies, treatment adherence, and crisis resources reinforced; teach-back accurate. Continued skilled monitoring indicated.

N4

Stable serious mental illness, adherent

Skilled psychiatric assessment completed for a patient with a stable serious mental illness. The patient is at the psychiatric baseline — no acute psychotic or manic symptoms, organized thought, and engagement as usual — and reports adherence to the prescribed regimen with tolerable side effects; denies thoughts of harm to self or others. Findings indicate a stable baseline on treatment. RN-level assessment was required to confirm the psychiatric baseline, screen for risk and acute symptoms, and evaluate adherence and side effects. Adherence, the plan, and crisis resources reinforced; teach-back accurate. Continued skilled monitoring indicated.

N5

Adjustment to illness, coping adequately

Skilled psychiatric assessment completed for a patient adjusting to a new medical diagnosis. Screens are low — some situational sadness without meeting a depression threshold — and the patient is engaging supports and coping adequately; denies thoughts of self-harm on screen. Findings indicate an adaptive adjustment without a disorder. RN-level assessment was required to screen mood and risk, distinguish an adjustment reaction from a depressive disorder, and reinforce coping. Coping strategies, supports, and crisis resources reviewed; teach-back accurate. Continued skilled monitoring indicated. (Psychosocial supports in the Psychosocial / Caregiver reference.)

N6

Interval mental-health check, no change

Skilled psychiatric assessment completed at the scheduled interval visit. Mood, affect, and anxiety are unchanged from baseline with low validated screens, the patient denies thoughts of harm to self or others, and there are no new psychiatric symptoms; treatment, where present, remains stable and adherent. Findings stable. RN-level assessment was required to confirm mental-health status against baseline with validated screens, screen for risk, and reassess the plan given the diagnosis. Coping strategies, adherence, and crisis resources reinforced; teach-back accurate. Continued skilled monitoring indicated.