Practicum – Assessing Client Family Progress
• Create progress notes
• Create privileged notes
• Justify the inclusion or exclusion of information in progress and privileged notes
• Evaluate preceptor notes
• Reflect on the client family you selected for the Week 3 Practicum Assignment.
Part 1: Progress Note
Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:
• Treatment modality used and efficacy of approach
• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
• 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
• The 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 (e.g., 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 family from the Week 3 Practicum Assignment.
In your progress note, address the following:
• 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 family’s progress note.
• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
The progress report will be from the below assessing client families case study paper from week 3.
Assessing Client Families
Family assessment focuses on evaluation family interactions to identify factors affecting children and the family at large (Simpson-Adkins & Anna, 2018). Family assessment involves interviewing children, analyzing the available information, meeting with family members, and identifying the root cause of the existing problem (Brown et al, 2015). This purpose of this assignment is to conduct a comprehensive family assessment for the client and the family. As per HIPAA regulations and for confidentiality and privacy purposes, pseudonyms will be used for all family members.
The family is made up of four family members, the father, mother, and their two sons. The father F.P 36-year-old Caucasian man is married to C.P a 33-year-old Africa American female. They have two children K. P (8 years) and H. P (2 years).
A neighbor had dialed 911 on hearing a continuous loud cry and scream from the apartment for about 2 hours. Initially, she had tried knocking at the door but there was no response. The police arrived and found the two children alone. The mother arrived home 30 minutes later while the father arrived an hour later, and the police noted that both parents were visibly impaired and very intoxicated. The two children were placed into protective custody. From the gathered information, the situation has been ongoing for a long time. The main concerns involve the care of the children along with unsatisfactory supervision allied to substance use. Supervision is a main ongoing concern for this family. According to neighbors and relatives, the children are always left unsupervised. Neighbors reported that the children are often found wandering in the streets. Some family members also reported that the parents use alcohol and drugs and thus even when physically present at home they are often unable to supervise the children adequately.
History of Present Illness
Father and mother reported that the day the children were placed in protective custody, they did not have any drugs to use. They are addicted to (methamphetamines). The father reported that he noticed during morning hours they were able to cope without the drug. However, in the afternoon their anxiety significantly increased and they both became edgy as time passed. In the late afternoon, the youngest son (H. P) slept and they decided to lock the door, left him alone in the house to go buy meth because the craving was becoming unbearable. However, on arriving at the shop, they started using meth rather than returning home with the drug as earlier planned. They lost track of time as they continued using meth and chatting with friends. On returning home, they were both high on drugs and found the law-enforcement officers were at their house.
Both F. P and C. P do not have any history of mental health problems.
No one in the family has a significant health problem. However, both children are behind on immunizations.
Substance use History
F. P and C. P have been using drugs and alcohol since their teenage years.
Both of them did not have any development problem.
Family Psychiatric History
F. P’s father used to have a substance use disorder and depression. No one in C. P’s family has had a mental health problem.
The family of Fredrick stays in the same house that Fredrick’s father bought him. F.P is the family breadwinner though he rarely works. When not high on drugs, he works as an electrician. The family does not identify with any religion although they report to sometimes attend Christian church services together. Both F. P and C. P often socialize with their friends and attend parties within the estate.
History of Abuse/Trauma
F. P does not have any history of abuse. However, C. P was sexually molested when she was 13 years old. From then on, she started using drugs and alcohol to forget the terrifying incident.
Review of Systems
HEENT: Both clients deny any pain or difficulty swallowing, no vision or hearing problems noted.
Respiratory: Respiration is even and unlabored for both clients
Gastrointestinal: No abdominal pain or upset and regular bowel movement for both client
Genitourinary: No pain or blood in the urination for both client
Skin/Breast: No problem noted for both clients
Neurologic: Both clients are alert and oriented, no sensation deficits noted
Musculoskeletal: Both clients are able to move all extremities without any difficulty.
-Vital signs & Measurements: Vital signs for both clients is within norm limits.
Pain Assessment: No complaints of pain noted from both clients.
Mental Status Examination
Both parents appear their age, clean and well-groomed for the occasion. Both have limited eye contact with the interviewer and cooperative. Both speeches are a little pressured, the mother’s mood seems depressed, both parents have poor judgment and limited insight of the situation. They are both worried about losing their kids
The parents are using drugs and alcohol which has greatly contributed to their poor parenting. Neglect and inadequate supervision for their children. Such neglect can lead to both physical and mental harm to the children (Syyder & Merrit, 2016).
• Inadequate children supervision
• Substance abuse disorder by the parents
The family consists of four members, the parents and two children aged 8 years and 2 years. A neighbor called 911 after hearing screams from the neighboring apartment. There was no response from them after knocking and thus the neighbor decided to call the police. After the police arrived, the children had been left alone unsupervised. The parents arrived later, and they were both visibly intoxicated and impaired. Both neighbors and some relatives reported that the parents are alcohol and drug addicts. They often leave their children unsupervised. As a result, the two children were placed into protective custody. Both father and mother acknowledged that their substance and alcohol use had significantly affected their capacity to be good parents and adequately supervise their children. They reported that they often leave their children alone to go look for drugs. They are also aware that it was not safe to leave the children alone and report that they will not leave children alone in the future.
• The parents will support the children while in placement
• The parents will sign all required releases
• The parents will attend parenting education classes for 12 weeks to learn about good parenting skills.
• The parents will ensure attendance of all visitations with the children and will be ready to have a safe and suitable interactions and activities with the children
• The parents and placement guardians will always keep the social worker informed
• The parents will gradually stop substance and alcohol use
• The parents will go through a drug and alcohol detoxification program to be clean and free of drug and alcohol.
• Develop a plan for effective and adequate supervision of the children
Strategy: A specific action plan will be developed for both C. P and F. P to ensure that alcohol and drug use does not affect their ability to always keep their children safe and supervised. This will be done in collaboration with the chemical dependency provider. A plan to assist F.P and C.P to avoid, cope and escape from high-risk circumstances that will result in drug use will be developed (Conrod, 2016). They will share their specific action plan with the social worker; social worker will help them to share the plan with the Children Welfare staff and team members to make sure they are informed of any change.
Social Support System
• F. P’s parents
• C. P’s parents
• Other relatives
Brown S, Wendy M & Bart S. (2015). Family Structure and Child Well-Being: Integrating Family Complexity. J Marriage Fam. 77(1), 177–190.
Conrod P. (2016). Personality-Targeted Interventions for Substance Use and Misuse. Curr Addict Rep. 3(4), 426–436.
Syyder S & Merrit D. (2016). The Effect of Childhood Supervisory Neglect on Emerging Adults’ Drinking. Subst Use Misuse. 51(1), 1–14.
Simpson-Adkins J & Anna D. (2018). How Do Children Make Sense of their Parent’s Mental Health Difficulties: A Meta-Synthesis. J Child Fam Stud. 27(9), 2705–2716.