Case: 
 
Mr. J, age 42, is a construction worker in Las Vegas. He recently noticed that a mole on his face seemed to be getting larger and darker. At first he did not worry because he was in the sun a lot and assumed the change may have been caused by sunburn. After a month, not only was the mole larger and darker, but it appeared to be “bumpy.” His doctor diagnosed a malignant melanoma skin cancer following biopsy of the nevus. Mr. J reports pain in his right shin that does not go away when he puts his feet up or sleeps.
Discussion Questions

• 1) Relate Mr. J’s skin changes to the warning signs for malignant melanoma.
• 2) Discuss the normal progression of this malignancy.
• 3) What is the significance of the bone pain that Mr. J is experiencing?
• 4)Discuss the treatment available for this patient and the prognosis for recovery.

Three Questions I might ask the client

1. Have you had any thoughts of suicide or causing harm to yourself or others in the past month? I am asking this question because if the client has major depressive disorder and the client is currently taking Paxil which can increase the risk for suicide in adults (Wiese, 2011).
2. How would you describe your sleeping patterns? The client stated she was abused as a child, therefore I want to establish if she is having nightmares or trouble sleeping related to the memories and flashbacks. This question can also help me establish if the client may have a sleeping disorder as well.
3. Do you have friends or close family members that you spend time with? Or friends that you go out with? Depression can have an impact on the client’s daily lifestyle which means she may not participate in her usual activities. The client may also withdraw from social activities and become uninterested in spending time with people.

Identify People in the client’s life I need to speak to
The client’s family history includes having family members with major depressive disorder (MDD) which means that her family members are the first people to interview to gain better insight about her behavior and patterns. The interviews can focus on past psychiatric history and if they are aware of anything she may have left out from her statements or medical history. I think it may be beneficial to interview the attending physician to see if he has something to add to her initial evaluation notes. The primary care physician can help if she has pre-existing conditions that may contribute to her current psychiatric symptoms. The client also mentioned attending psychotherapy sessions. I would want to interview the therapists to know if the patient is compliant with therapy goals and medication regimen during treatment. The purpose of the interviews it to develop an effective treatment plan for the client.
Diagnostic Tests and Physical Exams
The client has a history of substance abuse and has been attending support groups but it is still important to get a urine drug screen. The thyroid stimulating hormone (TSH) levels should be checked due to the thyroid gland being linked to having an influence on the brain with impacting the mood (Pilhatsch, Marxen, Winter, Smolka, & Bauer, 2011). The client should also receive a mental health examination considering we are trying to rule out different diagnosis and it is our first time with the client. The mental health examination will help establish a baseline like an annual physical.
Differential Diagnosis

1. Post-Traumatic Stress Disorder – According to the American Psychiatric Association (2013) PTSD involves exposure and serious injury which client experienced abuse as a child. The client reported having nightmares and flashbacks. PTSD symptoms also exist with other conditions such as the client’s history of alcohol and substance abuse (National Alliance on Mental Illness, 2017). I feel that the client mostly identifies with this diagnosis.
2. Major Depressive Disorder – The client’s PTSD and agitation are causing her to be depressed. Her depression is secondary and triggered by her nightmares. A persistent feeling of sadness and loss of interest that interferes with the client’s daily functioning.
3. Substance Use Disorder – The client has used alcohol and other substances to cope with her PTSD symptoms. The use of alcohol and other substances is commonly seen with individual’s that experience PTSD symptoms as a coping mechanism. Half of the individuals seeking treatment for SUD have symptoms of PTSD (Berenz, 2012).

Two Pharmacologic Agents
Sertraline – The medication is indicated for use with major depression disorder and posttraumatic stress disorder. The medication should be started at 25mg orally daily and then re-evaluated at the follow up appointment in 4 weeks. One of the side effects is weight gain so the client would need diet and exercise counseling as well.
Wellbutrin – This medication would be good to add as an augmenting agent to be taken in the morning daily. The extended release tablet can be started at 150mg. The client should be able to report a decrease in insomnia symptoms. The preferred combination treatment by some clinicians is to use Wellbutrin and Zoloft together to improve symptoms (Stahl, 2013).
Follow up checkpoints
I believe the client would have benefited from Sertraline and received a more positive outcome at the follow up visits. Sertraline combined with the Wellbutrin would have been more effective with treating the depressive symptoms and PTSD.  The follow up appointments revealed that the client’s appetite was curved and there were no problems with weight gain. The medication was also treating her depressive symptoms. The client should still be monitored for suicidal thoughts because she is always at risk for suicide while having depressive episodes and taking antidepressant medications.
Lesson Learned
Client safety is always the goal when prescribing medications for treatment. The PMHNP should fully understand that monotherapy may not be effective to treat the symptoms and to consider combination therapy for certain clients. The client has more than one disorder showing that polypharmacy may be indicated for more effective results in treatment. The treatment plan should be revisited at every follow up appointment and make the necessary changes as needed dependent on how the client is responding to the current treatment. The PMHNP will take into consideration how the client feels and any decisions she may have about her treatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Berenz, E. (2012). Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current Psychiatry Reports, 14(5), 469-477. doi: 10.1007/s11920-012-0300-0
National Alliance on Mental Illness. (2017). Posttraumatic Stress Disorder. Retrieved from https://www.nami.org/learn-more/mental-health-conditions/posttraumatic-stress-disorder
Pilhatsch, M., Marxen, M., Winter, C., Smolka, M., & Bauer, M. (2011). Hypothyroidism and mood disorders: Integrating novel insights from brain imaging techiniques. Thyroid Research, 4(S3). Retrieved from https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/1756-6614-4-S1-S3
Stahl, S. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applicatons (4th ed.). New York, NY: Cambridge University Press.
Wiese, B. (2011). Geriatric depression: The use of antidepressants in the elderly. BC Medical Journal, 53(47), 341-347. Retrieved from https://www.bcmj.org/articles/geriatric-depression-use-antidepressants-elderly

Stage 2: Sharing Data
Overview
Before you begin work on this assignment, be sure you have read the Case Study and reviewed the feedback received on your Stage 1 assignment.  Refer to the System Recommendation Report Table of Contents below to see where you are in the process of developing this report.
As a professional medical consultant, your next step in developing your recommendation for an EHR system is to determine what data will need to be shared with other organizations and how that data will be shared.
System Recommendation Report
                            Table of Contents
Introduction (Stage 1)​
I. Organizational Analysis and Requirements (Stage 1)       A. Introduction​B. Organizational StrategyC. Strategic Use of TechnologyD. Components of an Information SystemE. RequirementsF. SummaryII. Sharing Data (Stage 2)  A. IntroductionB. Need to Share DataC. Types of Data to be SharedD. Data Interchange StandardsE. SummaryIII. Ethical, Legal and Regulatory Policy Issues (Stage 3)A. IntroductionB. Table of Ethical, Legal and Regulatory Policy IssuesC. Addressing the Most Difficult IssueD. SummaryIV. System Recommendation (Stage 4) A. IntroductionB. Proposed IT solutionC. How the Proposed IT Solution Meets the RequirementsD. Improvements from Proposed IT SolutionE. Implementation ConsiderationsF. Summary
Conclusion (Stage 4)
References
System Recommendation Report (SRR), Section II – Sharing Data
Section II of the SRR document addresses the need for the Midtown Family Clinic to share data with other organizations.  As part of analyzing the requirements for the new system, one step is to consider how that system will enable the Midtown Family Clinic to exchange electronic data with other health organizations – such as other providers, pharmacies, insurance companies, and even patients themselves.  The case study mentions several of these.  For this assignment you will select two types of external organizations and describe what kind of data would flow between the Midtown Family Clinic and those organizations and how that can be done effectively.
Stage 2 Assignment Instructions
The first step is to incorporate the feedback you received on your Stage 1 assignment, making any needed corrections or adjustments.  Although the incorporation of feedback will not be graded until the final Report is submitted in Stage 4, it will assist you going forward to incorporate feedback at each stage.  For this assignment, you will add Section II of the System Recommendation Report (SRR).
Using the case study, the overview above, Course Content readings, and external resources, develop your Section II on Sharing Data.  Approximate lengths for each section are provided as a guideline; be sure to provide all pertinent information.  Apply specific information from the case study to address each area listed below.
II.     Sharing Data
A. Introduction  – Introduction to this section describing what is included. (3-4 sentences)
B. Need to Share Data – Review the Midtown Family Clinic Case Study and identify two types of external organizations (e.g., hospitals, nursing homes, rehabilitation centers, laboratories, pharmacies, health insurance providers, etc.) with which the Midtown Family Clinic needs to communicate and the purpose of the communication. (Introductory sentence and list of two external organizations and the purpose of their communication with the Midtown Family Clinic, providing specifics from the Case Study.) 1. External Organization #1 and purpose of communication.2. External Organization #2 and purpose of communication.
C. Types of Data to be Shared  – In Stage 1, Section C.3., Data, you took an initial look at the types of data the new EHR system will process.  But now we’re going to take that a step further and add a layer of complexity by considering the needs and requirements of different external organizations.  Using the two external organizations you listed in Section A above, list five data items, or data elements, that would be shared with each external organization, and explain whether that information is going out from the Midtown Family Clinic or coming in from each of the two external organizations.  Feel free to consult the list you developed for Section C.3 of your Stage 1 assignment.  Some of these data elements may come from that list if they are appropriate for this purpose; however, other, different, data elements may be listed here. Note: For full credit, a different list of data elements should be provided for each organization (no duplicates in the table below, although data elements may be repeated from Section C.3). (Provide an introductory sentence and copy the table and insert information within.)
​
Organization #1 (replace with your organization from above)
Data Element or Item
Data Goes TO/FROM Midtown Family Clinic
1.
2.
3.
4.
5.
Organization #2 (replace with your organization from above)
Data Element or Item
Data Goes TO/FROM Midtown Family Clinic
1.
2.
3.
4.
5.
D. Data Interchange Standards – Conduct some external research and identify a data interchange standard that would apply to the data that is exchanged with each external organization.  The standard you select should apply to one or more of the data elements you listed above for each organization.  Provide a brief description of what the standard is, what it requires, why it is important and how it applies to the data elements listed and the Midtown Family Clinic EHR system.  Note:  For full credit, two different data interchange standards are required.  (There are some specific data interchange standards that apply to health data exchange; if the same standard applies to the data exchanged with both organizations, explain how it relates to each.) (Introductory sentence and list of two external organizations and the information shown about the Data Interchange Standard selected for each, providing specifics from the Case Study.) 1. External Organization #1a. Data Interchange Standard and descriptionb. What the Data Interchange Standard requires in order to be able to use it in an information systemc. Why the Data Interchange Standard is importantd. How the Data Interchange Standard applies to the data elements listed and the Midtown Family Clinic EHR system2. External Organization #1a. Data Interchange Standard and descriptionb. What the Data Interchange Standard requiresc. Why the Data Interchange Standard is importantd. How the Data Interchange Standard applies to the data elements listed and the Midtown Family Clinic EHR systemE. Summary – briefly summarize the content of this section and tie the information together for the reader. (3-4 sentences)
Formatting Your Assignment
For academic writing, the writer is expected to write in the third person. In third person, the writer avoids the pronouns I, we, my,you, your, and ours. The third person is used to make the writing more objective by taking the individual, the “self,” out of the writing. This method is very helpful for academic writing, a form in which facts, not opinion, drive the tone of the text. Writing in the third person allows the writer to come across as unbiased and thus more informed.  The Report is to be written for the Midtown Family Clinic, and reference should not be made by name to individuals who own or work in the Clinic.
• Include the Introduction and Section I, revised according to any feedback received, and add to it Section II.• Write a short concise paper:  Use the recommendationsprovided in each area for length of response.  Content areas should be double spaced; table entries should be single-spaced. It’s important to value quality over quantity.  Section II should not exceed 4 pages. • Ensure that the table is preceded by an introductory sentence that explains what is contained in the table, so the reader understands why the table has been included.• Use at least two resources with APA formatted citation and reference.  Use at least one external reference and one from the course content. • Compare your work to the Assignment Instructions above and the Evaluation Criteria/Grading Rubric below to be sure you have met content and quality criteria.  Do not overlook this step.  Read your work out loud or have your computer read it to you.  Fix the grammar and other areas identified.  • Submit your paper as a Word document, or a document that can be read in Word.  • Your submission filename should be as follows:  Lastname_firstname_Stage_2

Using as reference:
Title: Integrating Quality and Strategy in Health Care Organizations
Edition: 1st (2013)
Author: Sadeghi, Sarmad / Shabot, M. Michael / Barzi, Afsaneh / Mikhail, Osama Publisher: Jones & Bartlett Book
ISBN: 978-0-7637-9540-5
Chapters 7-9 (Sadeghi, Barzi, Mikhail, & Shabot)
In not less than 250 words Discuss
In the healthcare setting measuring quality is what the quality teams like to make sure is excellent.  Pretend, that you are the new quality improvement director at the hospital. You have evaluated tons of patient surveys, complaints, and clinical patient data reports. What steps would you take to improve the quality and would you assemble together a quality team to help make improvements to your hospital?  What steps would you take to measure the current level of quality at the hospital?
In two different paragraph with not less than 100 words give your personal opinion to Elena Mears and  Dianna Adair
Dianna Adair
The first steps for improving quality are to make sure there is a clear business performance measurement to track quality, as it says in the book, for quantifying the quality performance gaps. There should be clear tracking of safety, efficacy, efficiency, equity, time, and patient-centeredness (Sadeghi, Barzi, Mikhail, & Shabot, 2013).
I would say assembling a small team (if the hospital can spare them) of department leads to meet and discuss quality concerns and implement quality changes would be a good idea. I would work with these department leads to come up with a plan that aligns with how their departments work as well as the overall organizational needs using the aforementioned items being tracked.
For examples of how these measures can be tracked, safety could be measured in how long it has been since a staff member or patient has been injured on the premises or the percentage of healthcare workers using proper PPE and handwashing during random daily checks plus patient reports from surveys. Timeliness could be measured by how long it takes for test results to be processed, how long patients wait in the waiting area and also in the exam room, and how long total the patient spends in the facility grouped by severity. I won’t go into examples for everything because I don’t want to write a novel, but you get the idea.
To improve safety measures, we should aim for 100% on patient surveys when asking about if the nurse or doctor wore fresh gloves and cleaned their hands, as well as with random checks by head nurses or other designated staff. To improve timeliness, set goals for how long things should take in normal circumstances, and aim to hit those targets at least 80% of the time.
In order to hit targets, staff could be subjected to training modules on the computer, meetings to remind them of targets and ask what they need to be provided to make it happen. Each department head would be responsible for their department meeting goals, and I would oversee and evaluate their progress and see if the department heads need to be doing things differently based on how the organization does as a whole.
Regards,
Dianna
References:
Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating Quality and Strategy in Health Care Organizations. Burlington, MA: Jones and Bartlett Learning.
Elena Mears
What is measured is achieved.   I’m not sure where this saying comes from, but it seems true of most organizations.  In healthcare as with other industries, it’s key to build a team of internal stakeholders and users who can set expectations of quality and interpret the resulting measurements within the organization.    Once that team is in place, the first step is to determine what should be measured.
If organizational quality has never been measured in the facility, organizations such as the National Quality Strategy (NQS) provide tools and guidance to build a program (AHRQ, 2017).  Mirroring the six aims of the Institute of Medicine (IOM) – safety, effectiveness, patient-centered, timeliness, efficiency, and equitability – will ensure that the facility is following established indicators of healthcare industry quality (Sadeghi, 2013).    Experts suggest starting with five generic measures:  technical quality, customer satisfaction, speed, product cost reduction, and cash flow from operations (Sadeghi, 2013).
For example, to assess patient satisfaction, the facility could use an industry standard patient satisfaction survey, and have it administered by an outbound call center after the patient has discharged from the hospital.  The results of the survey should be linked to the patient’s functional status before and after hospitalization in order to determine if the treatment or outcome was positive (Joshi, et al., 2014).  The resulting data would be reported to the quality improvement team.
References
About the National Quality Strategy. (2017). Retrieved from http://www. ahrq.gov/ working.
forquality/about/index.html
Joshi, M., Ransom, E. R., Nash, D. B., & Ransom, S. B. (2014). The Healthcare Quality Book:
Vision, Strategy, and Tools: Vol. Third edition. Health Administration Press.
Sadeghi, S. et al. (2013). Integrating quality and strategy in health care organizations.
Burlington, MA: Jones & Bartlett Learning.