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
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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.
The Assignment 2: Practicum – Assessing Client Progress Assignment
Part 1: Progress Note
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 Assignment 2: Practicum – Assessing Client Progress
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. Assignment 2: Practicum – Assessing Client Progress
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.
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 Assignment 2: Practicum – Assessing Client Progress 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) Assignment 2: Practicum – Assessing Client Progress
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. Assignment 2: Practicum – Assessing Client Progress
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. Assignment 2: Practicum – Assessing Client Progress
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.
Reference
Dick, R, Steen, E (Editors): 1991. The Computer Based Patient Record; Washington DC, National Academy Press.
Practicum – Assessing Client Family Progress
Part 1: Progress Note
Subjective
The client admits that both psycho-educational and interpersonal therapies have been efficient considering his ability to manage his anger and depressive episodes. He reports that the family therapy has enabled him to change the perception of his diagnosis and drug regimen despite his inability to resume work. Assignment 2: Practicum – Assessing Client Progress. However, the client is concerned about the performance of his son who he thinks has been affected by his reckless behavior in the past. At 14 years and attending school, he believes that the boy may not benefit from the therapy. He also feels the same for his wife who is always busy at school or performing house chores in the evening. All members of his family are supposed to attend all therapy sessions for optimal outcomes. Consequently, he feels that he is presently not benefiting from the family therapy sessions since he can only benefit from supportive therapy considering the extent of his illness.
Objective
Mr. J.K maintained calmness throughout the sessions. He made sound remarks to approve the strategies aimed at improving his condition. Despite the few challenges during the meeting, the client demonstrated satisfaction and a willingness to continue with the therapy at the end. He claimed that he was prepared enough to overcome attempts to withdraw from the interventions. Of the three members of the family, he was the only one that attended all the sessions. His wife missed three, while the son missed five. Assignment 2: Practicum – Assessing Client Progress.
Assessment
In as much as the client presented a few episodes of weariness and sadness during the family therapy, the review of the system, physical evaluation, and the mental status exam did not reveal any abnormalities. The same can be said of the other members of his family who had been dressed appropriately for the day and session. They were all oriented to time, place and person. The patient presents to the session with alcohol use disorder and admits he uses tobacco and marijuana. He resorted to abusing alcohol after being diagnosed with stage two lung cancer. At the time the diagnosis was made, Mr. J.K felt that only alcohol consumption would enable him to overcome the grief and anxiety of having to live with the deadly disease. The support from his family has been insignificant, primarily due to the busy schedule of his wife as well as by the fact that she has suffered depression in recent months. She attributes the depression to her husband’s illness, alcohol consumption the burden of having to support the family single-handedly.
Plan
There is a need for the therapist to consider making changes to his schedule to ensure that all members of this family benefit from the sessions. Becvar & Becvar, (2017), share the same assertions in their article. The client’s wife who has reportedly suffered from depression will require to attend all the family therapy sessions so that she may find better ways of supporting her son and husband who has been reduced to supportive and palliative care by his illness. Assignment 2: Practicum – Assessing Client Progress. The therapy sessions also need to take into consideration the school timetable to enable the 14-year old boy to attend them. He has been affected adversely by the current illnesses that both his parents are suffering from in the last few years. The therapist should prescribe antipsychotics for the client’s wife to make sure that she can put her moods under control. However, there is a need for the family to make sure that they progress with the interpersonal and psychoeducation therapy for at least three weeks for better outcomes (Weitz et al., 2015). There is an immense need for each one of them to change their thoughts and general perception about life and resume the activities of daily living.
Part 2: Privileged Note
Mr. J.K provides a perfect example of a person that is frustrated in life due to his reckless behavior. His excessive intake of alcohol has not only resulted in being sacked by four different employers but has also been arraigned in court for dangerous driving. Besides diagnosis of stage 3 lung cancer and spouse depression episodes complicates the family. The mental status examination does not reveal any incidences of him being suicidal or homicidal, but the actions make a justification. The failure to put in place therapeutic interventions for this patient may result in the loss of his life through reckless actions. Had the therapist visited the family a bit earlier, the family would not be experiencing the challenges they are in at present. The client would not have resorted to consuming alcohol in excess amounts as a strategy to overcome the grief and sorrow that comes with a lung cancer diagnosis. Assignment 2: Practicum – Assessing Client Progress.
The information presented in the privilege note could not be displayed in the progress note because of the HIPAA regulations concerning privacy and confidentiality Weitz et al., 2015). This information is intended for use by a therapist alone and no other party. It is not uncommon for my preceptor to use the privilege notes to preserve the information on the experiences of those with psychiatric conditions. This information guides the development of strategies that guide the treatment of these disorders (American Psychiatric Association, 2013).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing.
Becvar, R. J., & Becvar, D. S. (2017). Systems theory and family therapy: A primer. Rowman & Littlefield.
Weitz, E. S., Hollon, S. D., Twisk, J., Van Straten, A., Huibers, M. J., David, D., … & Faramarzi, M. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs. pharmacotherapy: an individual patient data meta-analysis. JAMA Psychiatry, 72(11), 1102-1109. Assignment 2: Practicum – Assessing Client Progress