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 Pr

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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.

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 Pr
Running head: Assignment 2: Practicum 0 Assignment 2: Practicum – Assessing Client Progress NURS 6640 There are differences regarding what is documented in the patient’s record and the scribed personal observations of the psychotherapist. Indeed, this paper will explore the soap note by utilizing information from week three. Also, there will be a week-three privilege note constructed, along with a discussion of the differences of the privilege note and the notes made in the patient’s medical record. Week Three SOAP Note 12/12/19 14:00 (S) “I feel depressed, stressed anxious, and unbalanced.” Also, patient stated, “I get shaky and sweaty.” Recent History: The patient reports problems in his marriage, intimate relationships, and with others including paranoia, reduced sleep and appetite, worried about finances, excessive talking. Personal History: The patient had mental treatment at Hospital USA decade ago. Previous diagnoses include bipolar disorder, schizophrenia disorder, and history of substance abuse. The patient was raised by both parents, including one older brother, and a younger sister. The patient stated that his family moved around a lot, and he “never was stable in school. Also, patient was on psychiatric medication as a child, and witnessed violence between his parents, and violence on the streets where he grew up; additionally, the client reports witnessing a friend overdose on drugs. The patient stopped attending school around age 13 after he was “put out by school security.” The patient left home at age 13 due to his mother not providing – “she was a heroin addict.” (O) Flight of ideas with rapid, loud, paranoid, persecutory, trouble concentrating pressured speech, and frequently labile mood (A) Bipolar 1 disorder, depressed, severe [F31.4, DSM code] and Generalized Anxiety Disorder [F41.1, DSM code]. Clinical impressions: Rule out Bipolar I given the hypomanic symptoms. (P) Rescheduled for 01/12/20 @ 2 p.m.; Prognosis fair, due to the patient’s current hypomanic state. Patient to see Dr. N after therapy for psychotropic medication session to review the current medication regimen of Prozac and Trazadone. Referred to NAMI for family therapy. Next session: Continue cognitive behavioral therapy sessions and assign reading homework: Cognitive-Behavioral Therapy Program–Workbook by Grant, Donahue, and Odlaug) (Cameron & Turtle-Song, 2002). Part Two: The Privilege Note 12/12/19 14:00: During the meeting with the patient, I noticed that the patient was more manic than usual, which leads me to believe he may not be completely compliant with his medication regimen. Moreover, the patient’s marital problems may also be exacerbating his bipolar condition and increasing his insomnolence; thus, there may need it will be essential to review the effectiveness of the current psychopharmacology in the next session. In summary, I believe that the client has plateaued his motivation toward his therapeutic goals; nevertheless, I will defer confronting this concern until after reviewing the progress with the patient at the end of the next meeting (The Differences Between Psychotherapy Notes and Progress Notes, 2018).  Privilege Note Versus Progress Note Privilege notes are the personal notes of the psychotherapist’s observations and impressions of the patient. The privilege note will include items such as the psychotherapist’s hypothesis, observations, thoughts, and feelings regarding the patient’s unique condition. The privilege notes serve as an essential tool that the clinician refers to when determining an effective treatment plan (The Differences Between Psychotherapy Notes and Progress Notes, 2018).  . Also, privilege notes are kept separate from medical records and billing information, and providers must have the patient’s authorization before sharing the notes; paradoxically, the patient does not have a right to access the privilege notes (The Differences Between Psychotherapy Notes and Progress Notes, 2018).  Preceptor’s Privilege Notes The preceptor utilizes privilege notes in her everyday practice. Indeed, the preceptor will scribe observations and opinions immediately after the meeting. The preceptor takes no more than a few minutes to make the privilege note, and she will refer to them in the next meeting (Cameron & Turtle-Song, 2002).  Conclusion The clinician must understand the nuances of patient documentation. Indeed, documentation in the patient’s medical record contains data pertinent to the direct care of the patient. In contrast, the privilege note serves the clinician as a personal record of impressions and observations. Ultimately, both types of notations serve to enhance the patient’s overall standard of care. References Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development, 80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x Psychotherapy Notes and HIPAA. (n.d.). Retrieved January 12, 2020, from https://psychcentral.com/lib/psychotherapy-notes-and-hipaa/ The Differences Between Psychotherapy Notes and Progress Notes. (2018, June 8). ICA Notes. https://www.icanotes.com/2018/06/08/the-differences-between-psychotherapy-notes-and-progress-notes/ References Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development, 80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x
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 Pr
Practicum – Assessing Clients Psychotherapy Individual: Prac 6640 6/21/2020 Practicum – Assessing Clients Part 1: Comprehensive Client Family Assessment Demographic Information Name: Camila R DOB: 2/20/1988 Age: 32 Gender: Female Race: Hispanic American Facility: REH Crisis Stabilization Program City: Minneapolis State: MN Presenting Problem Substance abuse, social withdrawal, and excessive worry. History or Present Illness Camila is an immigrant from Mexico. She left the country in search for a well-paying job that could cater to her needs and those of her family. However, so far, she has only managed to get minimum-wage jobs, which are not able to sustain both her and her family. Consequently, she has entered a depressive state due to her constant worrying about the future. She uses marijuana and alcohol as coping mechanisms. Shanmugam (2017) notes that this is a common trend among many addicts. Her constant worrying has made her irritable and withdrawn from her friends. Camila feels that she needs to get over her mental problems if she is to keep on working hard for the sake of her family. Past Psychiatric History Camila has noted that most of her days are spent worrying about money and where she can find a good job that will meet all her needs adequately. Consequently, she has had to depend on drugs and alcohol for solace. Whenever she is high, she forgets about her issues. However, her substance abuse is getting out of hand because it is affecting her performance at work. She has been irritable, angry, unable to get along with others, had mood swings, and has even had thoughts of suicide. Camila worries that if this trend continues, she will lost the only job she has with no guarantees of getting another one soon. Medical History Camila has been taking prescription antidepressant medication. She has been consuming 20 mg of Prozac per day. The medication has made her feel better but has not eradicated her problem. Substance Use History Camila has abused alcohol for approximately eight years. She has also taken excessive amounts of marijuana for the past year. She desires to be treated for both her substance abuse and her mental problems. Developmental History There is no available history since Camila is an immigrant from Mexico and has only stayed in the country for one year. Family Psychiatric History There are no records of Camila’s family psychiatric history. Psychosocial History Camila’s problems have made her withdrawn from her friends and family. She rarely interacts with close friends and prefers meeting with strangers whose she feels will not judge her apparent ‘failure in life,’ as she puts it. History of Abuse/Trauma Camila was raped on her way home from work this year. This episode triggered her excessive use of marijuana to cope with the feelings of shame. Acierno, Resnick, Flood, and Holmes (2003) assert that many women turn to drugs after being raped to handle the emotional turmoil. She did not report this case to the local authorities or to her family, preferring to suffer alone. Review of Systems General: Camila appears to be oriented to her surroundings. She answers queries succinctly and appears to be of sound mind. However, she only weighs 100 lbs. This is quite low for a woman whose height is 5’10. She attributes this to lack of appetite. Skin, Hair, Nails: All these factors appear normal. HEENT- Camila states that she does not have a headache. However, due to her poor eating habits, she regularly experiences dizziness and has even had syncope in the past. Her vision and hearing are relatively good. Cardiovascular: Camila states she has never had any chest pains or heart issues. Her BP is 120/80. She has a regular heartbeat of 90 beats per minute. She has a regular heart rate of 90 beats per minute. Pulmonary: Despite being a smoker, Camila says she has no breathing or respiratory issues. She has a 98 percent oxygen saturation. Gastrointestinal: Camila’s bowel movements are regular. Genitourinary: Camila’s urinary pattern is regular Neurologic: Camila states that she has never been diagnosed with a neurological problem. Musculoskeletal– Camila states that she has never been diagnosed with a musculoskeletal problem. However, she has slight back and knee pains. Hematology: Camila states that she has never been diagnosed with any blood disorders or malignances. Endocrine: Camila’s endocrine functions are normal. Physical Assessment Camila is alert and appears her age. However, she is underweight (100 lbs) for a height of 5’10. As aforementioned, her vitals are normal, that is cardiovascular, pulmonary, neurological, and gastrointestinal, among others. Mental Status Exam Camila was very coherent during the exam. She tried to maintain constant eye contact and effectively answered all questions concisely. However, she was moody and appeared distant at times. She was fidgeting all the time and noted it was due to her withdrawal from alcohol. Nonetheless, she was not delusional or paranoid. She was aware of her mental issues, which she stated had adversely affected her relationship with her family and friends. Camila took the Patient Health Questionnaire-9 (PHQ-9) and got a score of 25, which depicts severe depression. Differential Diagnosis Camila was diagnosed with severe substance abuse and depression. Case Formulation Camila’s mental issues have likely arisen from her inability to cater to the needs of her family. Everyone seems to look up to her and she is overwhelmed with the responsibility bestowed upon her. Additionally, the rape incident made the situation worse. Treatment Plan Goal 1 Camila will successfully undergo treatment for drug and alcohol abuse. Objective Camila will take all the necessary steps to be admitted into Park Avenue Women’s Center. Intervention Camila will be subjected to motivational interviewing. This model takes the form of counselling where the patient is encouraged and pushed to adopt positive behavioral changes. The changes are expected to lower Camila’s addictive habits. Goal 2 Camila will effectively reduce and manage her social withdrawal, excessive worry, and anxiety Objective Camila will adopt effective coping skills through therapy techniques and use of antidepressant medication. Intervention Camila will be subjected to cognitive therapy and antidepressants. Part 2: Family Genogram Camila’s child is 10 years old Camila is separated from her daughter’s father Camila’s extended family lives in Mexico References Acierno, R., Resnick, H. S., Flood, A., & Holmes, M. (2003). An acute post-rape intervention to prevent substance use and abuse. Addictive Behaviors, 28(9), 1701-1715. Shanmugam, P. K. (2017). Alcoholism & Drug Dependence. Journal of Alcoholism & Drug Dependence, 5(4).

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