Assignment 2: Assessing Client Progress – Practicum

Assignment 2: Assessing Client Progress – Practicum

Assignment 2: Assessing Client Progress – Practicum

Assignment Instructions. Please read carefully to the end before starting

Assignment 2: Practicum – Assessing Client Progress

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)

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.)

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.

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.

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)

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.

Client from Week 3 Assignment: 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).

Past psychiatric history

1- Major Depressive disorder, Recurrent Episode with psychotic features

2- Alcohol use disorder; severe

3- 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.

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.

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.

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.

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.

Differential diagnosis

1- Major Depressive disorder, Recurrent Episode with psychotic features

2- Alcohol use disorder; severe

3- Bipolar I Disorder most recent episode depressed Severe

4- Recurrent Episode with psychotic features (DSM-5, 2018).

Columbia Suicide Severity Rating Scale:

1- Wish to be dead: Yes

2- Suicidal thoughts: yes

3- Suicidal thoughts with method (with a specific plan and intend to act): Yes

4- Suicidal Intend (with particular plan): Yes

5- Suicidal Intend with a specific plan; Yes

6- 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).

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).

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: Assessing Client Progress Sample Paper

Name:

Course:

Professor:

School:

City and State:

Date:

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.

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.

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.

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.

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)

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.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. Assignment 2: Assessing Client Progress – Practicum

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Assignment 2: Assessing Client Progress – Practicum

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