Assessing Client Progress

Assessing Client Progress

· 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) Assessing Client Progress

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 Assessing Client Progress

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 Assessing Client Progress

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. Assessing Client Progress

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. Assessing Client Progress

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. Assessing Client Progress

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. Assessing Client Progress

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 Assessing Client Progress

Medical history

None Reported

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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. Assessing Client Progress

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 Assessing Client Progress

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. Assessing Client Progress

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. Assessing Client Progress

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. Assessing Client Progress

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). Assessing Client Progress

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 Assessing Client Progress

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