Practicum – Assessing Client Progress Essay Assignment

Practicum – Assessing Client Progress Essay Assignment

Assignment 2: Practicum – Assessing Client Progress
Learning Objectives
Students will:
Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
To prepare:
Reflect on the client you selected for the 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.Practicum – Assessing Client Progress Essay Assignment
The Assignment
Part 1: Progress Note

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

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)
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.)Practicum – Assessing Client Progress Essay Assignment
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.Practicum – Assessing Client Progress Essay Assignment

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.
Explain why the items you included in the privileged note would not be included in the client’s progress note.
Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

Note: Please refer to the attched client information. References should be no more than 5 years old.Practicum – Assessing Client Progress Essay Assignment

Assessing clients

Part 1: Comprehensive client family assessment

Demographic information

Patient Name: J.H..

Sex: Male

Date of birth: 11-17-07

Age: 11 years

Religion: Catholic - Christian

Legal Status: Minor - Dependent

Preferred Language: Major – Latino, Minor - English

Presenting problem

The patient is reported to have poor academic performance in his 5th grade school. The issue was first identified by his teacher who reported the same to his parents. Other than academic activities, the gym teacher also reports that the patient does not perform well in sports and social activities, always appearing as a loner. The parents and teachers concur that the patient has been generally inattentive by failing to pay close attention both at home and in school over the last one year. This is particularly seen when he spaces out during conversations and class activities. The patient reports that: “I dislike engaging in activities that have me thinking a lot or managing hard tasks.”Practicum – Assessing Client Progress Essay Assignment

History of present illness

Over the last one year, the patient has reported typical attention deficit hyperactivity disorder (ADHD) symptoms that include interrupting, fidgeting, excessive talking, and unable to sit still in certain situations. Smith (2012) and Wheeler (2014) both concur that these symptoms are typically reported in ADHD.

Past psychiatric history

The parents report that the patient has been of sound psychiatric health.

Medical history

The parents report that the patient was diagnosed with asthma three years ago. The asthma is controlled through the use of Advair inhaler 100/50 1 puff INH BID and Proventil inhaler two puffs INH prn.

Substance use history

Neither the parents nor the patient have any history of substance abuse.

Developmental history

The parents report that there have been no delays.

Family psychiatric history

No psychiatric conditions in the parents’ family history.

Psychosocial history

The patient is not sociable and tends to be a loner. However, his parents are very sociable and have him tag along for social activities involving the extended family members. Practicum – Assessing Client Progress Essay Assignment

History of abuse/trauma

There is no history of abuse or trauma with the parents adding that they encourage the use of dialogue in solving problems. The patient has never been subjected to corporal or physical punishment.

Review of systems

General: No night sweats or fever.

Skin: Normal baldness pattern due to aging with no changes to the skin.

Head: No history of seizures, dizziness, trauma, headaches, or trauma.

Eyes: No field or vision changes, or glaucoma diagnosis.

Ears: No vertigo or tinnitus.

Nose: No running nose, facture history or epistaxis.

Mouth and Throat: No pain or sores.

Neck: No pain, goiter or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.

Genitourinary: No urination urgency or frequency, or dysuria.

Neurologic: No paresthesia, tingling or numbness.

Musculoskeletal: No joint or muscle pain.Practicum – Assessing Client Progress Essay Assignment

Hematologic: No history of transfusion, anemia or bleeding disorder.

Emotional: No history of abnormal adjustments, depression, or psychiatric problems.

Physical assessment

Vital signs completed: 1:38

B/P: 126/73

Pulse: 66 BPM

RR: 17 BP

Temp: 37oC

Pulse Ox: 99%

Weight: 30 kg

General appearance: Oriented and alert with no acute distress.

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Skin: No abnormal lesions or moles noted.Practicum – Assessing Client Progress Essay Assignment

Neck: No masses.

Cardiovascular: Regular rhythm and rate, no gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Mental status exam

The patient was initially cooperative but lost interest towards the end of the interview.

Differential diagnosis

The patient suffers from ADHD given the presented symptoms and results of the assessment.

Case formulation

The patient is brought in to address the ADHD.Practicum – Assessing Client Progress Essay Assignment

Treatment plan

The patient should be subjected to a long-acting medication to address the ADHD since they increase the probability of compliance, are confidential and convenient (Bray & Kehle, 2011). The first formulation is methylphenidates whereby four options are open for consideration. The first option is Ritalin LA that will be presented as 60 milligrams, formulated as soda and that acts for 10 hours. The second option is Focalin XR that is taken as 30 milligrams, formulated as soda and that acts for 12 hours. The third option is Concerta that is taken as 30 milligrams, formulated as soda and that acts for 12 hours. Finally, is the Dayana Patch that is presented as 30 mg and formulated as a transdermal patch (Shier et al., 2013).Practicum – Assessing Client Progress Essay Assignment

The second formulation is amphetamines whereby two options are available. The first option is the Adderall XR that is provided once daily as 60 milligrams, acts for 10 to 12 hours and involves the immediate release of 50% of the drug with the sustained release of the remaining drug over time. The second option is the Vyvanse that is provided once daily as 70 milligrams, acts for 12 hours and is presented as a capsule of d-amphetamine and l-lysine that must be hydrolyzed to release the drug (Shier et al., 2013). In this respect, either of the six options can be used on the patient, depending on availability and convenience of the drugs. Still, the medications that have the longest duration of activity offer the best treatment alternative and should be administered in the morning of every day.Practicum – Assessing Client Progress Essay Assignment

Other than the medication, the patient should be subjected to behavioral training to enable her develop close relationships, acquire social skills, reduce antisocial and undesirable behaviors, and gain social problem-solving skills (Katona, Cooper & Robertson, 2012).Practicum – Assessing Client Progress Essay Assignment

 Part 2: Family genogram

References

Bray, M. & Kehle, T. (2011). The Oxford handbook of school psychology. Oxford: Oxford University Press.

Katona, C., Cooper, C. & Robertson, M. (2012). Psychiatry at a glance (5th ed.). Hoboken, NJ: Wiley-Blackwell.Practicum – Assessing Client Progress Essay Assignment

Shier, A., Reichenbacher, T., Ghuman, H. & Ghuman, J. (2013). Pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: clinical strategies. Journal of Central Nervous System Disease, 5, 1-17. doi: 10.4137/JCNSD.S6691

Smith, G. (2012). Psychological interventions in mental health nursing. Berkshire: Open University Press.

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.Practicum – Assessing Client Progress Essay Assignment