Assignment 2: Practicum – Assessing Client Progress Essay

Assignment 2: Practicum – Assessing Client Progress Essay

To prepare:

  • Reflect on the client you selected for the Week 3 (See the attached case study for client selected in week 3) Practicum Assignment.
  • Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format (See attached resource).

The Assignment

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): (See sample paper)

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Treatment modality used and efficacy of approach

Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)Assignment 2: Practicum – Assessing Client Progress Essay

 

Modification(s) of the treatment plan that were made based on progress/lack of progress

 

Clinical impressions regarding diagnosis and/or symptoms

 

Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)

 

Safety issues

 

Clinical emergencies/actions taken

 

Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

 

Treatment compliance/lack of compliance

 

Clinical consultations

 

Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)

 

Therapist’s recommendations, including whether the client agreed to the recommendations

 

Referrals made/reasons for making referrals

 

Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)

 

Issues related to consent and/or informed consent for treatment

 

Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

 

Information reflecting the therapist’s exercise of clinical judgment

 

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.

The privileged note should include items that you would not typically include in a note as part of the clinical record.Assignment 2: Practicum – Assessing Client Progress Essay

 

Explain why the items you included in the privileged note would not be included in the client’s progress note.

Assignment 2: Practicum – Assessing Client Progress Essay

Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

 

References

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

  • Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)
  • Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

 

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)Assignment 2: Practicum – Assessing Client Progress Essay

 

Note: You will access this article from the Walden Library databases.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

 

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.Assignment 2: Practicum – Assessing Client Progress Essay

Comprehensive Client Family Assessment

Demographic Information

Date of assessment: 09/14/2018.        DOB: 011/01/1970.                Age: 48.          Race: Black.

SSN: 000000001.     Ethnicity: African American.    Address: On file.    Tel: 972-000-0000.

Residential Status: Homeless.             County: 9K.           Military Status: None.

Language: English.     Interpreter Needed:  No.         Primary Insurance: Uninsured.

Annual Gross Income: $0.      Employment Status: Unemployed.

Number of people in the household:  1.         Highest Grade: 11.

School Attendance for the past 3 Months:  None.

Arrival Time: 1000   Time Disposition Completed: 1100

Location of client: Lake Worth Nursing Home

 

Presenting Problem

“My meds are not working.”

 

History of Present Illness

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife.  The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).Assignment 2: Practicum – Assessing Client Progress Essay

 

Past psychiatric history

  • Major Depressive disorder, Recurrent Episode with psychotic features
  • Alcohol use disorder; severe
  • Bipolar I Disorder most recent episode depressed Severe

 

Medical history

None Reported

 

Substance use history

Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.

 

Developmental history

None Reported

 

Family psychiatric history

Positive for family history of mental illness on the paternal side.

 Psychosocial history

The patient is unemployed and enjoys hanging out with fellow drunkards on the street with drinks, a living condition currently unstable as the patient is homeless.

 Assignment 2: Practicum – Assessing Client Progress Essay

History of abuse/trauma

The patient suffered abuse paternal uncle at age 12.

Review of systems

General:  significant weight gain recently, positive with fatigue, but no fever or a cough.

HEENT: vision and hearing changes not reported at this time, no history of glaucoma, cataracts, diplopia, floaters, excessive tearing or photophobia, last eye exam four years ago. No ear infections, tinnitus or discharges in the ear, have no problems with smell, and taste. Denies epistaxis or nasal drainage, no any loose teeth, mouth sores or bleeding gum when brushing teeth. No difficulty with chewing or swallowing.Assignment 2: Practicum – Assessing Client Progress Essay

Neck: positive for JVD, no bruits

Respiratory: Denies shortness of breath, labored breathing, cough, but could be exposed to TB.

Cardiovascular: S1 and S2, RRR. No Shortness of breath reported, denies chest pain, palpitations, No difficulty during exercise.

GI: No nausea, vomiting, heartburn, indigestion.  No changes in bowel/bladder pattern, bowel sounds present on all four quadrants.

GU: No change in urinary pattern, hematuria or dysuria.

Musculoskeletal: WNL, No joint pain or swelling.

Psych: Positive for the history of mental health, reports anxiety, depression suicidal ideation but no homicidal thoughts.

Neuro:  Alert, oriented x 3, no fainting, dizziness, or loss of coordination, positive for weakness.

Skin: warm to touch and moist, denies any skin changes, rashes or raised lesions, no itching, no history of skin disorders or cancers, no swelling.Assignment 2: Practicum – Assessing Client Progress Essay

Hematologic: No bleeding disorders or clotting issues, no history of anemia or blood transfusions.

Allergic/Immunologic: Penicillin- rash and seasonal allergies, Sulfa drugs - rash.

 

Physical assessment

Vital signs: B/P 130/78; P 70 regular; T 98.4 orally; RR 20 non-labored; RBS 100mgdl; Wt: 140 lbs.; Ht: 5’6; BMI 22.6.

 Assignment 2: Practicum – Assessing Client Progress Essay

Mental status exam

The level of consciousness: cerebral perfusion, coherent thought, concise responses.

Mood: Depressed and sad.

Behavior: Appropriate/Normal and cooperative.

Cognition: displays signs of hallucination and compulsion.

Personal hygiene and grooming: deteriorated grooming and personal hygiene.

Memory and attention: AO x 3.

 Assignment 2: Practicum – Assessing Client Progress Essay

Differential diagnosis

  • Major Depressive disorder, Recurrent Episode with psychotic features
  • Alcohol use disorder; severe
  • Bipolar I Disorder most recent episode depressed Severe
  • Recurrent Episode with psychotic features (DSM-5, 2018).

Columbia Suicide Severity Rating Scale:

  • Wish to be dead: Yes
  • Suicidal thoughts: yes
  • Suicidal thoughts with method (with a specific plan and intend to act): Yes
  • Suicidal Intend (with particular plan): Yes
  • Suicidal Intend with a specific plan; Yes
  • Suicidal behavior question: Yes

If yes to 6, how long ago did you do any of these: Over a year ago (American Psychiatric Association, 2013).

 Assignment 2: Practicum – Assessing Client Progress Essay

Case formulation

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife.  The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).Assignment 2: Practicum – Assessing Client Progress Essay

 Treatment plan

The client will begin an antidepressant Sertraline (Zoloft) 25 mg PO daily for the next four week and monitor progress. Start patient on an alcohol detox program to help with dependency and encourage to client join the alcohol anonymous (AA) group for support (Wheeler, K., 2014). Assignment 2: Practicum – Assessing Client Progress Essay

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Question

Differentiate progress notes from privileged notes

Privileged records is a set of information which involves only two parties, the client and the therapist and this information remains confidential, and even the law does not permit forceful disclosure of the content. On the other hand, a progress note is a medical record where a medical practitioner or psychiatrist records details of a patient, the clinical status and the progress they have made during therapy.

Question

  • Reflect on the client you selected for the Practicum Assignment.
  • Review the Cameron and Turtle-Song (2002) article on this week’s Learning Resources for guidance on writing case notes using the SOAP format.Assignment 2: Practicum – Assessing Client Progress Essay

Progress Note

Name of Patient:

Date:

Subjective

Amabella suffers from mental distress as a result of being in an abusive marriage for almost fifteen years. Due to the constant abuse, she has developed mild depression as well as anger issues. Her health has deteriorated which has led to weight loss caused by malnutrition.

I have gone through her past medical history in an attempt to investigate any medications she has been under in the past. I have also enquired about any family or social history that would have led to her condition. (Dick, S, 1999, 41)

Objective

Her physical exam findings show that her body is bruised and full of stubborn scars which are a result of being forcefully grabbed or hit with blunt objects. Her neck also reveals that she has been chocked severally. Also, there is a fresh wound cut on her face.Assignment 2: Practicum – Assessing Client Progress Essay

Assessment

The therapeutic sessions have been productive. Amabella is collaborative and is improving. She is open when talking about why she thinks her husband is an animal and whether he can change or not. She does not get as angry and aggressive as she used to when our treatment sessions began. She is now calm, lively and happier. Her health is also improving.Assignment 2: Practicum – Assessing Client Progress Essay

Plan

I have found it very useful to involve a marriage counselor during the therapy to assist because marital issues are beyond my level. I recommended it to her, and she agreed. Afterwards, I have helped Amabella get a competent divorce lawyer who has legally advised her about the whole divorce process as well as her rights upon leaving the toxic marriage. She agrees to this for it is good for the safety of the children and her too. The divorce papers will be ready soon, and she will be moving to her new apartment in a few days.Assignment 2: Practicum – Assessing Client Progress Essay

 

Privileged Note

Question

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your

Answer

My client was troubled at the beginning of our sessions. She disclosed that apart from physical torture from the husband, she was also sexually abused. In fact, the children know what their dad was doing to their mother. She was almost reaching her breaking point, but after completing her therapy, her attitude has changed. Her being able to open up helped a lot.

The above-privileged note includes vital information about abuse in Amabella’s marriage. Sensitive issues like rape are covered, which should be regarded as highly confidential information which should not be disclosed to any other party. (Steen, B, 1999,37)Assignment 2: Practicum – Assessing Client Progress Essay

My preceptor uses privileged notes because I prefer to discuss my issues with him alone because I like my right to privacy to be respected. If other people know my problems, it would increase my mental illness.

References

Dick, R, Steen, E (Editors): 1991. The Computer Based Patient Record; Washington DC, National Academy Press.

Client is here for routine scheduled Mental Health follow up appointment. This visit included 30 minutes of medication management and supportive psychotherapy.

Subjective:

“I am starting to feel myself again”

 

Client is prescribed fluoxetine and trazodone forMDD, recurrent, moderate, insomnia.

She states she is doing better since our last meeting, she reports less feelings of sadness, less anergia, denied anhedonia or amotivation, no further crying episodes.  She reports sleeping has improved to 5.5 hours/24 hrs.  appetite is increased; however, she has not gained any weight.  Concentration is improved.Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denies past or present episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous. Assignment 2: Practicum – Assessing Client Progress Essay

activities, self-inflated ego, grandiosity, or promiscuity.

Denies any medication side effects.  Reports compliance.

Last substance use: alcohol 1 glass of wine daily. Denied illicit drug use, no nicotine, caffeine drinks/day.

Reviewed active outpatient medication list/reviewed labs. Client reports last menstrual cycle 5 days ago, denied risk of pregnancy, she has IUD.

Suicide Inquiry:  Denies suicidal ideations, intentions, or plans.  Denies recent self-harm behavior. Talks futuristically.

Assignment 2: Practicum – Assessing Client Progress Essay

Objective:

 

Allergies: PCN (hives)

 

Psychiatric medications:

Fluoxetine 40mg po daily for depression

Trazodone 50mg po bedtime for sleep as needed.

 

Global Suicide Risk Assessment: The Client is found to be at Low riskof suicide or violence.  However, risk level increased under context of alcohol or illicit drug use.

Assignment 2: Practicum – Assessing Client Progress Essay

Patient Questionnaire:

PHQ-9:  12

Previous PHQ-9: 20

Assignment 2: Practicum – Assessing Client Progress Essay

Assessment:

 MENTAL STATUS EXAMINATION: She is a48 yo Hispanic female who looks her stated age. She is cooperative with examiner. She is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. Her speech is clear, coherent, normal in volume and tone. Her thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. Her mood is dysphoric but improving, and her affect appropriate to her mood. She was smiling at times in an appropriate manner. She denies any auditory or visual

hallucinations. There is no evidence of any delusional thinking.   She denies any current suicidal or homicidal ideation.  Cognitively, she is alert and oriented to all spheres. Her recent and remote memory is intact. Her concentration is good. Her insight is good. Assignment 2: Practicum – Assessing Client Progress Essay

 

Diagnostic Impression (based on DSM-5 criteria)

Major Depressive Disorder, recurrent, mod

Insomnia, unspecified

Client is a 48yo Hispanic female who presents for follow up medication evaluation appt after an increase to her fluoxetine medication, she reports noting improvements in her mood and her sleep.  Her depression has moved from a severe level to a moderate level in the past 30 days.  No noted anxiety, no evident mania/hypomania, no psychosis.  She admits to drinking one wine/night, no illicit drug use, caffeine does not appear to be a contributor to her insomnia at this time as she stops caffeine by 3pm.

Assignment 2: Practicum – Assessing Client Progress Essay

At the time of disposition, the Client adamantly denies SI/HI ideations, plans or intent and has the ability to determine right from wrong, and can anticipate the potential consequences of behaviors and actions. She is a low

risk or self-harm based on her current clinical presentation and her risk and protective factors. Based upon current assessment, at this time the least restrictive and safe environment for care is in the outpatient setting.

PLAN:

1) Medication: will hold her fluoxetine at 40mg po daily for mood for the next 30 days and continue to monitor improvement in mood.    Instructed to call and report any adverse reactions.

Future Plan: if mood continues to improve at current dose will maintain; if mood begins to decline or no improvement will consider increase fluoxetine 60mg po daily for mood next appointment

Assignment 2: Practicum – Assessing Client Progress Essay

2) Education:  Risks and benefits of medications are discussed including non-treatment. Potential Side Effects Of Medications Discussed. Verbal informed consent obtained.Not to drive or operate dangerous machinery if feeling sedated. Not to stop medication abruptly without discussing with providers. Assignment 2: Practicum – Assessing Client Progress Essay

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs.  Instructed to avoid this practice. Encouraged abstinence.  Discussed how drugs/ETOH affects mental health, physical health, sleep

architecture. Discussed risky drinking levels for females: more than 3 drinks on any day or 7 per week

3) Clientis scheduled for weekly CBT with LCSW on Thursdays. Reminded her of appointment

4) Client has emergency numbers:  Emergency Services 911, the national Client's Crisis Line 800-273-TALK. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

5) Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Assignment 2: Practicum – Assessing Client Progress Essay

6) RTC in one month

7) Safety Plan Reviewed

Client is amenable with this plan and agrees to follow treatment regimen as discussed.

Assignment 2: Practicum – Assessing Client Progress Essay