Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
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.
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.)
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
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.
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.
Children: Patient has no children
Paternal and Maternal Grandparents, all Negative
REVIEWS OF SYSTEM:
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
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.
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.
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