treatment plan progress notes - All ShadowHealthAssessments

Assignment 2: Practicum – Assessing Client Progress

Name

Institution

Part 1: Progress Note

Treatment Modality Used and Efficacy of Approach

The client in this case is undertaking cognitive behavioral therapy to help manage her anxiety and other mental disturbances. This psychological approach is effective in treating virtually all the mental health disorders and hence presents an appropriate approach for the case (Kaczkurkin & Foa, 2015).

Progress

The client demonstrates significant improvement in managing her anxiety and though patterns. She has been able to identify anxiety triggers, learnt breathing and relaxation techniques and other non-pharmacological interventions. Her depressive and anxiety symptoms have also reduced significantly over the course of treatment.

Modifications

Minimal modifications were done to the treatment plan since the client was cooperative and willing to get better. Having a family therapy can help change the attitude of the family members and the spouse and help them provide social support by understanding her situation (Jadav & Sharma, 2018).

Clinical Impressions

The client’s symptoms included poor performance in academics demonstrated by her failure in the nursing class. She presents moderately dysphoric mood, lack of attention and concentration, negative thoughts, low self-esteem associated with her past failures, decreased interest in activities, feelings of unimportance, poor energy and severe impaired in concentration and psychomotor retardation (Gazzillo, Dimaggio & Curtis, 2019). She has increased worry and muscle tension.

Psychosocial Information

The client is a nursing student and unemployed. She is not married but dating a spouse who does not approve of her studies. She lives with her family that does not provide any social support and feels that she should have chosen a different major. None of the family members has been to college.

Safety Issues

The safety issues associated with the client’s condition include the risks of self-harm and suicidal thoughts associated with depression (Bruns & Letcher, 2018). In addition, she could become a drug addict since she drinks socially during the weekends which can aggravate her mental and physiological condition.
Clinical Emergencies

There are no clinical emergencies associated with the patient’s condition.

Medications

The client is under no prescribed or unprescribed medications.

Treatment compliance

The patient adheres to the treatment plan as required. She is determined to seek counselling and engage in cognitive behavioral therapy to promote her recovery. She has taken measure to recognize her stressors and dysfunctional thoughts, record them and device a healthier thought pattern and put them into practice by week three of CBT.

Clinical Consultations

Clinical consultations were conducted through phone calls, emails and messages. The client also visited the clinic for follow up appointments with the psychiatrist.
Collaboration with other Professionals

Treatment involved collaboration between the psychiatrist, physical therapist, physician and the family therapist. This helped monitor the progress of the client, device appropriate CBT activities and involve the family in the treatment plan (Tzur Bitan & Lazar, 2019).

Therapist’s Recommendations

The therapist recommendations include compliance and consistency with the CBT and maintenance of positive thought processes. The client was in agreement with the recommendations.

Referrals

No referrals were made. The client was very responsive to the treatment plan.

Termination/issues

The client termination was unscheduled. Following her positive recovery within a short time, she decided to end the session due to the financial constrains associated with her lack of job and insurance cover that would cover her continued attendance.

Informed Consent, Child Abuse and Therapists Exercise of Clinical Judgment

The client consented to her treatment plan. The practitioner provided information regarding her condition, the treatment plan and the expected consequences. This supported informed consent as required by the psychiatrist nursing guidelines.

Abuse

The client has not experienced any form of child or elder abuse.

Therapist’s exercise of clinical judgment

The clinical judgment was conducted based on the objective and subjective information obtained from the client. As such, the clinical judgment involved informed and collaborative decision making between the client and the therapist.

Part 2: Privileged Note

A privilege notes was utilized in documenting and analyzing the therapeutic session conversations. It provided the basic information outline concerning what was addressed during the session. In this case, the items excluded from the note include the initialization and completion of the session, the treatment frequency and modalities, the patient’s clinical test results, diagnostic and prescription medication summary and monitoring. In addition, the treatment plans and status of functioning, symptoms, prognosis and summary of the progress note are not included.

The reason for exclusion of the above items was to prevent turning the privilege note into a progress note. Typically, the privilege note should contain the items left out from the progress note and they provide more details regarding the patient’s condition for privacy purposes, the Health Insurance Portability and Accountability Act of 1996 protects this information considering its sensitivity and confidentiality.

The preceptor utilizes privilege noted to document their conversations during the sessions they have with their patients. The preceptor includes the observations made during the therapy session, thoughts and feelings regarding situation of the clients’ psychiatric diagnosis hypothesis and the uniqueness of the patient’s condition. This document assists in the documentation, analysis of the issue and the formulation of effective plans for treating the client. However, the preceptor’s notes do not follow a particular format.

References

Bruns, K. L., & Letcher, A. (2018). Protective Factors as Predictors of Suicide Risk Among Graduate Students. Journal of College Counseling, 21(2), 111–124. https://doi-org.ezp.waldenulibrary.org/10.1002/jocc.12091

Gazzillo, F., Dimaggio, G., & Curtis, J. T. (2019). Case formulation and treatment planning: How to take care of relationship and symptoms together. Journal of Psychotherapy Integration. https://doi-org.ezp.waldenulibrary.org/10.1037/int0000185

Jadav, R., & Sharma, A. (2018). Effectiveness of Non-Pharmacological Management of Anxiety for Patients going for General Anaesthesia-A Literature Review. International Journal of Nursing Education, 10(4), 104–108. https://doi-org.ezp.waldenulibrary.org/10.5958/0974-9357.2018.00113.7

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346.

Tzur Bitan, D., & Lazar, A. (2019). What do people think works in psychotherapy: A qualitative and quantitative assessment of process expectations. Professional Psychology: Research and Practice, 50(4), 272–277. https://doi-org.ezp.waldenulibrary.org/10.1037/pro0000241

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.
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.
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.

Enclosed is my assign week 3 practicum and the patient that I used Psychiatry New Evaluation History and Physical

Patient MRN: 0000
Date of Service: 9/13/19

Presenting Problem: “Difficulty concentrating and increased anxiety”

HPI: Our patient is a 29-year-old female, with no formal psychiatric history, who presents with moderate symptoms of depression and anxiety in context with poor academic performance. She stated that she failed her nursing class three times and, on the verge, to be kicked out of the nursing program. She states that her family is not supportive of her career and she attributes to the fact that none of her family went to college. She states that they do not even support her decision to come in for an evaluation. She states that her family believes that she can “handle it” without seeking professional help. Her significant other also has been unsupportive, stating that she should stop studying so much and spend time with him.

During the evaluation, her mood was moderately dysphoric, and has progressively worsened for the last 8 months. This has been aggravated by the feature mentioned above. Patient also has negative thoughts regarding her ability to pass the class, poor self-esteem due to recent class failures and inability to see positive outcomes regarding her situation. Other new depressive symptoms include reduced interest in activities, feelings of unimportance, poor energy and severe impaired in concentration and psychomotor retardation. She does not have any history of prior self-harm thoughts, denies any thoughts of hurting herself or others.

The patient also meets criteria for generalized anxiety disorder. Symptoms include muscle tension, difficulty concentrating, increase worry.

Home medications:
None

Allergies: NKDA

Past psychiatric history:
No Formal Psychiatric History

Past medical history:
No past medical history

Social history: Patient is a nursing student at a local college. She currently does not work. She states that her family are not supportive of her career and wishes she would pick a different major. She denies any recreational drug use and drinks socially on the weekends.

FAMILY HISTORY:
Father: unknown
Mother: Negative
Children: Patient has no children
Paternal and Maternal Grandparents, all Negative

REVIEWS OF SYSTEM:
Cardiovascular Negative
Constitutional Negative
Endocrine Negative
Eyes Negative
ENT Negative
Gastrointestinal Negative
Genitourinary Negative
Neurologic Negative
Respiratory Negative
Integumentary Negative
Psychiatric no manic episodes, or symptoms, no prior traumatic events, no delusions, no hallucinations, no prior self-harm attempts, has moderate to severe anxiety, positive for depression screen, all other ROS negative)

Vitals: Blood pressure __133/100 Heart Rate _89_ Pulse Ox 98% RA__ Resp Rate 18

Musculoskeletal Exam: Muscle strength 5 of 5 times 4 extremities, Gait and station intact

Mental Status Exam:
A&Ox4, Cooperative, dressed casually, well groomed, with moderate psychomotor retardation. Mood moderately dysphoric, affect congruent, restricted, with a normal intensity. Speech fluent with proper syntax, prosodic, with decreased spontaneity, no abnormalities in rate, articulation, or volume. Thoughts slightly circumstantial, no flight of ideas, no looseness of associations. Thought content logical and focused on care plan, and severity of symptoms, no self-harm thoughts. No delusions, no perceptional disturbances. Cognition intact, however inattentive, with impaired concentration. Good fund of knowledge, no abnormalities in language, able to name objects and repeat phrases. Recent and remote memory intact, estimated intellectual functioning average, Moderate to good insight, has awareness of mood symptoms, good judgment.

Diagnostic Studies: Patient advised to have baseline labs drawn by PCP

Differential Diagnosis:
1. Rule out generalized anxiety disorder
2. Rule out major depression disorder
3. Rule out ADHD

Case Formulation: includes a complete and rational picture of what the patient is trying to pursue in psychotherapy in spite of the obstacle that prevent the patient for pursuing her goal.

1. Presenting Issues: difficulty concentrating and anxiety.
2. Factors to create vulnerability to precipitate problem: poor academic performance and poor social support and family never gone to college. Although these are present, the patient also has protective factor such as emotional stability and flexibility (Bruns & Lether, 2018). This is apparent in that patient continued to persevere and continue with her schooling to meet her goals.
3. Factors not involve in the initial problem that help maintained problem: she is working and studying, unforeseen events like car trouble and missed two practicums and that is automatic fail.
4. Factors to help patient cope: She is determined to seek out counseling, tutoring, filled out a request form to extend test time and to take the tests in a quiet environment. According to Tzur & Lazar, psychotherapy is known to be effective for patients with depression and anxiety (2019). She has taken measure to recognize her stressors, including not knowing her learning style in which she has implemented interventions to figure out her best learning style. For instance, studying power points, attempting to record lectures, and pictures to learn better by auditory or visual.

Treatment Plan:
1. Cognitive behavioral therapy once a week for eight weeks. Most research has acquired the effectiveness and efficacy of CBT for anxiety including PTSD, GAD, and phobias.
2.Patient will recognize dysfunctional thoughts, record them and device a healthier thought pattern and put them into practice by week three of CBT.

3.Manage anxiety triggers by implementing non-pharmacological interventions such as deep breathing exercises, imagery to promote relaxation by week three of CBT. Non pharmacologic intervention is the best way to reduce anxiety. Patients benefits and also promote patient’s comfort through enhancing stress threshold by regulating the internal process of the body and improve immunity.
4. Report decrease anxiety and depression symptoms by the end of week five.

References:

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346.