Mental Health SBAR
Date: September 26, 2050
I. Situation
The patient, Naomi Ortiz, a 32-year-old female, is currently admitted to [Your Company Name] following a manic episode associated with her diagnosis of Bipolar I Disorder. She presents with elevated mood, decreased need for sleep, and increased goal-directed activity. The current treatment plan includes mood stabilizers and psychotherapy. The team must evaluate her response to treatment and discuss the plan for transitioning her to outpatient care.
II. Background
Naomi has a history of Bipolar I Disorder diagnosed at age 25. She has had multiple hospitalizations over the past few years due to severe manic and depressive episodes. Previous treatments have included various mood stabilizers and antipsychotic medications, with mixed results.
Her recent hospitalization was prompted by an escalation in manic symptoms, including reckless spending and impulsivity. During her stay, she has been stabilized on Lithium and Lamotrigine, showing significant improvement in mood stability and insight into her condition.
Relevant Medical History
Year | Event |
|---|
2048 | Hospitalized for a manic episode |
2049 | Stabilized on new medication regimen |
2050 | Recent hospitalization due to worsening symptoms |
Family History
Social History
III. Assessment
Naomi's current mental status is significantly improved compared to admission. She is alert, oriented, and engages well in discussions. However, there are ongoing concerns about her impulsivity and decision-making abilities, particularly related to her financial management and social interactions.
Mood: Euphoric but stable
Insight: Improved; acknowledges the need for ongoing treatment
Risk Assessment: Moderate risk of relapse; financial decisions require monitoring
IV. Recommendation
Continue current medication regimen: Monitor Lithium and Lamotrigine levels closely, ensuring therapeutic levels are maintained.
Outpatient follow-up: Schedule an outpatient appointment with a therapist specializing in mood disorders within one week of discharge.
Psychoeducation: Provide Naomi with information about her condition and strategies for managing symptoms, including identifying early warning signs of relapse.
Family Involvement: Recommend involving her family in her care plan to enhance support and accountability, particularly concerning financial decisions.
For further information or to discuss this SBAR in detail, please feel free to reach out to me at [Your Email] or contact [Your Company Name] at [Your Company Email]. You can also reach me at [Your Company Number] if you have any questions or need additional insights regarding Naomi's case.
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