WK 7 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.(attaching)
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
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
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. Assessing Client Progress Essay
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.
By Day 7
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Submission
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Click the Week 7 Assignment 2 link.
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Grading Criteria
To access your rubric:
Week 7 Assignment 2 Rubric
Check Your Assignment Draft for Authenticity
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Submit your Week 7 Assignment draft and review the originality report.
Practicum – Assessing Client Progress
Progress Note: SOAP (Subjective, Objective, Assessment, Plan)
Subjective
“I feel used by my family … my husband whom I thought would be with me for the rest of my life is slowly drifting away….my two sons whom I raised with much care have not been much help and have similarly ignored me and my problems”.
The client reports that some days she feels sad and worthless but denied having sleep difficulties or appetite changes. The client stated that anxiety was erratic but denied feeling depressed or hopeless. In addition, she was concerned that her two sons only talk with her whey they need help while her husband ignores her unless there are business issues that should be addressed.
Objective
- Allergies: NKDA
- Medications: Lisinopril 25 mg PO daily
- Suicide Risk Assessment: None
The client is a Mrs. M is a 61-year-old woman, whose appearance seems appropriate for her age. The client appears alert and oriented to both time and place. She appears sad, as manifested by a gloomy face. Her posture is erect.
Vitals: B/P: 138/88; Pulse: 82 BPM; RR: 18 BP; Temp: 37oC; Pulse Ox: 96%; Weight: 69 kg
Assessment
MENTAL STATUS EXAMINATION: The client is oriented to time, place, situation, and person. She has an appropriate general appearance. She is well dressed with good hygiene. The client has good insight, judgment, attention, and concentration. Her speech is of a normal rate with soft volume. She has unremarkable motor activity, perception, and an organized thought process. She presents in a euthymic mood with a slightly anxious affect and is tearful at times. Assessing Client Progress Essay
Diagnosis: General anxiety disorder as manifested by irritability, nervousness, fatigue, restlessness, and worry (American Psychiatric Association, 2013).
Treatment Plan
- Obtain informed consent from the client
- The assessment data shows that the client manifests symptoms consistent with symptoms of general anxiety disorder, and therefore the recommended treatment is psychotherapy (Khdour et al, 2016).
- Psychotherapy: The client will attend regularly scheduled psychotherapy sessions to manage her current symptoms by guiding the patient in identifying and verbalizing her feelings, making lifestyle changes, learning coping skills, and applying relaxation techniques. Additionally, the psychotherapy will provide emotional support, stress management skills, and coping skills (Wheeler, 2014).
- Education: The client will be educated about anxiety management. She will be educated about stress management practices such as meditation and deep breathing exercises. In addition, she will be referred to a local support group so that she can get moral support from individuals undergoing similar experiences.
- Family counseling: The entire family will undergo counseling in order to facilitate her recovery. The husband and the sons will be informed about the concerns and feelings of the client and that they need to provide her with the necessary support to aid her recovery. In addition, the family members will be given information about the diagnosis for the client (general anxiety disorder) and how to avoid triggers for the client (Locke et al, 2015).
- The client will be informed about the importance of adhering to the recommended treatment regimen
- The client will be reviewed after four weeks
- Treatment Goals
- Short Term Goals: Anxiety symptoms for this client will reduce by 50% by the time she will be attending the review (after four weeks)
- Long Term Goal(s): The client will report complete symptom remission within three months
Privilege Note
The client cooperated and was calm during the entire session. However, I noted that she was very sad and kept mumbling how alone she felt. She is very ready to undergo treatment but confessed that if her family members were supportive, she would be attending the family business, and not wasting time in treatment. The client appears like she has low self-confidence, which might be traced back to her childhood trauma, and maybe a major contributing factor to her current condition. She appears to be very fond of her husband and the two sons but she is not ready to reveal her diagnosis to them. However, after convincing them the importance of involving the family members in her treatment, she agreed to have them informed of her diagnosis and be included in the treatment plan, especially in family therapy sessions. Personally, I think that the client does not get enough emotional support from both the husband and the sons. However, with family counseling, the family interactions will improve and adherence of the client to the prescribed treatment regimen will ensure that she eventually achieves complete symptom remission because her anxiety is not serious. Assessing Client Progress Essay
The information that was included in the privilege notes but was not included in the progress notes was the analysis of the content and information discussed with the client during the session. Therefore, the information in the privilege notes was my thoughts and feelings about the condition of the client. Items that should not be included in the privilege notes include the treatment plan and the diagnosis (Brattland et al., 2018).
The preceptor utilizes privileged notes and she includes items such as her personal feelings about the progress of the client. My preceptor also includes very private information in the privilege notes.
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Part 1: Comprehensive client family assessment
Demographic information
Patient’s Name: E. M.
Sex: Female
Date of birth: 09/12/1960
Age: 61 years
Religion: Christian Catholic
Ethnicity: Latino/Hispanic
Marital status: Married for 40 years
Children: Two sons
Work Status: Business owner
Preferred Language: High proficiency in English and Hispanic
Presenting problem
Mrs. M is a 61-year-old woman who is married to a 72-year-old man. She has been married for the last 40 years. She has two sons. She co-manages the family business with her husband. She has been referred by her general practitioner for psychiatric care with stress related concerns.
History or present illness
E.M. reports that she feels used by her husband and sons. She is particularly critical of her husband who has been engaging in extramarital affairs using the money from the business that they jointly built over the last 35 years. She is also critical of her sons who have largely ignored her unless they want money or help from her. She states, ‘I feel used by my family … my husband whom I thought would be with me for the rest of my life is slowly drifting away. I have given him the best years of my life and now he feels that I no longer have any use and a younger woman would be preferable. Besides that, my two sons whom I raised with much care have not been much help and have similarly ignored me and my problems.’ The state of affairs has caused Esperanza to exhibit stress related symptoms. Her general practitioner is concerned about the impact of the stress on her overall health. Assessing Client Progress Essay
Past psychiatric history
She has not had any psychiatric concerns although she attended grief therapy sessions more than a decade ago following the death of her parents in a plane crash.
Medical history
She has high blood pressure and is currently on Lisinopril to manage the condition.
Substance use history
She occasionally drinks in social occasions such as family gatherings and business meetings. On average, she takes three glasses of wine every week. She experimented with marijuana and cocaine as a teenager, and has not taken any drugs since she got married.
Developmental history
She does not have any known developmental issues.
Family psychiatric history
She was raised in Mexico City by an alcoholic mother and father. She has two siblings of which one was committed to a psychiatric facility having been diagnosed with depression.
Psychosocial history
She reports that her two sons only talk to her when they have issues and need her help. In addition, her husband mostly ignores her unless there are business issues to be addressed. She has a good relationship with her siblings and talks to them at least once every week.
History of abuse/trauma
She was physically abused by her parents who were alcoholics.
Review of systems
PSYCHIATRIC REVIEW OF SYSTEMS: Client reports having, “some sad days and feelings of worthlessness” but denies feeling hopeless or current depression. She denies having difficulty sleeping or appetite changes. She denies SI/HI. Client reports anxiety of 4/10 that “comes and goes”.
PAST MEDICAL/SURGICAL HISTORY: Client reports Appendectomy at age 23.
HOME MEDICATIONS: Lisinopril 25 mg po daily
ALLERGIES: NKDA
PAST PSYCHIATRIC HISTORY: none
-Prior psychiatric diagnoses: none
-Current psychiatric medications/start date/prescriber/efficacy: none
-Past psychiatric medications: none
-History of psychotherapy or ECT: none
-Hospitalization(s): No psychiatric admissions
-Past suicide attempts: none
-Current psychiatrist and phone #: n/a
-Current Therapist and phone #: n/a
Physical assessment
Vital signs completed:
B/P: 138/88
Pulse: 82 BPM
RR: 18 BP
Temp: 37oC
Pulse Ox: 96%
Weight: 69 kg
General: Alert oriented x’s 4. Has erect posture.
Head: No history of headaches.
Eyes: Uses prescription glasses to correct vision.
Ears: No vertigo.
Nose: No running nose.
Mouth and Throat: No pain, sores, or issues eating.
Neck: No pain or masses.
Cardiovascular: Regular rhythm and rate. No murmurs.
Lungs: No crackles or wheezes
Respiratory: No hemoptysis, sputum, wheezing, or cough.
Gastrointestinal: No black stools, diarrhea, vomiting or nausea.
Genitourinary: No urination urgency or frequency.
Neurologic: No paralysis.
Musculoskeletal: No joint or muscle pain.
Hematologic: No history of anemia or bleeding disorder.
Skin: Warm and dry without abnormal lesions, abrasions, bruising or moles.
Mental status exam
This Client has an appropriate general appearance. She is well dressed with good hygiene. Client has good insight, judgment, attention, and concentration. Her speech is of normal rate with soft volume. She has unremarkable motor activity, perception, and an organized thought process. She presents in a euthymic mood with a slightly anxious affect and is tearful at times. She is orientated to person, place, time and situation. Assessing Client Progress Essay
Differential diagnosis
This client is diagnosed as suffering from general anxiety disorder (F41.1). She is irritable, nervous, fatigued, restless, and worried; all symptoms that support the diagnosis. The differential diagnosis is adjustment disorder with depressed mood (F43.21). She feels sad, tearful and hopeless; symptoms that support the diagnosis (American Psychiatric Association, 2013; Sperry, 2016).
Case formulation
Childhood trauma especially connected to alcoholic parents has been linked to adult depression and anxiety in women (Das, 2019). This client agrees to ongoing psychotherapy to address her current feelings and symptoms also with regard to her history of abuse and childhood trauma. Will discuss possible need for concurrent anti-depressant therapy. Would also recommend family counseling.
Treatment plan
The patient will receive treatment that will entail attending regularly scheduled psychotherapy sessions that will manage her current symptoms through guiding the patient in identifying and verbalizing her feelings, making lifestyle changes, learning coping skills, and applying relaxation techniques. In addition, the psychotherapy will offer emotional support, as well as coping and stress management skills (Wheeler, 2014).
Part 2: Family genogram
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Das, A. (2019). Genes, Childhood Trauma, and Late Life Depressive Symptoms. Journal of Aging & Health, 31(8), 1503–1524. https://doi-org.ezp.waldenulibrary.org/10.1177/0898264319861001
Sperry, L. (2016). Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (3rd ed.). New York, NY: Routledge.
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. Assessing Client Progress Essay