NURS 335 Sue Doe Patient #3 Mental Health Treatment Plan

Patient Chart with Treatment Plan Patient Information Photo Patient Name: Sue Doe – Patient 3: Sue Mental Health Diagnosis: Major Depressive Disorder Date of Visit: Treatment Plan Non-Pharmacological Regimen - Patient was connected with the Health Care for the Homeless network to help get qualified and scheduled for cognitive behavioral therapy - Labs ordered: CBC, CMP, TSH, free testosterone, and total testosterone to rule out any underlying causes - Had patient complete the PHQ-9 questionnaire to refer to for comparison when patient comes back for her follow up Pharmacological Regimen - Will start patient on a low dose SSRI and taper up if needed, Sertraline (Zoloft) 50mg Patient Education - Take the medication daily - Medication will need to be taken for 2 to 4 weeks for a noticeable effect - Continue taking the medication even when feeling better - Do not stop taking the medication without checking with your provider - Some of the common side effects are dizziness, nausea, vomiting, dry mouth, sexual dysfunction, or suicidal thoughts or behavior - Patient educated she will need continued follow up for the next 6-9 months Referral (if not applicable, indicate none) - Referral to a psychologist for psychotherapy Follow Up - Patient is scheduled for a follow up in 2 weeks to assess effectiveness and side effects