5 REFERENCES NOT MORE THAN 5 YEARS
The patient is 59 years old African American male who was admitted to the long term due to declining in health. The patient is alert and verbally responsive. He was admitted with a diagnosis of Mood disorder, depression, and Bipolar disorder. Patient on the following medications: Risperidone 0.5mg 1 tab PO at bedtime. Depakote 250mg 3tabs PO at bedtime. The patient reported that he is feeling great today. The psychiatrist saw the patient in February, and no medication reduction was recommended. The patient was encouraged to not refused his medication and reported any unusual feelings.
- 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.)
- 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.
Expert Solution Preview
As a medical professor responsible for creating college assignments and evaluating student performance, I would design lectures, conduct examinations, and provide feedback to medical college students. In this assignment, I will provide answers to the specific content related to the patient scenario and the requirements stated.
Answer to the content:
Part 1: Progress Note
In the progress note for the client presented in the Week 3 Practicum Assignment, the following information should be included:
1. Treatment modality used and efficacy of approach: Detail the specific treatment modality employed, such as cognitive-behavioral therapy or psychodynamic therapy, and assess its effectiveness in addressing the client’s condition.
2. Progress and/or lack of progress toward the mutually agreed-upon client goals: Discuss the client’s progress towards the goals established in the treatment plan. Identify any advancements or obstacles encountered during therapy sessions.
3. Modification(s) of the treatment plan: Describe any necessary changes made to the treatment plan based on the client’s progress or lack thereof. Explain the rationale behind these modifications.
4. Clinical impressions regarding diagnosis and/or symptoms: Provide clinical impressions and insights regarding the client’s diagnosis and symptomatology. Include any observations or relevant changes in their mental health status.
5. Relevant psychosocial information or changes from the original assessment: Document any significant psychosocial information or changes in the client’s life circumstances since the initial assessment. These may include marital status, employment changes, or relocation.
6. Safety issues: Address any safety concerns or potential risks identified during the course of therapy. Outline actions taken to ensure the client’s safety and well-being.
7. Clinical emergencies/actions taken: Report any clinical emergencies that occurred during therapy sessions and the appropriate actions taken to manage them effectively.
8. Medications used by the patient: List the medications prescribed to the client, even if the nurse psychotherapist did not prescribe them. Include the specific dosage and administration instructions.
9. Treatment compliance/lack of compliance: Evaluate the client’s adherence to the recommended treatment plan. Note any instances of non-compliance and discuss the potential impact on therapy outcomes.
10. Clinical consultations: Document any consultations made with other healthcare professionals, such as physicians, psychiatrists, or family therapists, to ensure comprehensive care for the client.
11. Collaboration with other professionals: Describe any collaborative efforts undertaken with other professionals involved in the client’s treatment, including phone consultations and shared treatment recommendations.
12. Therapist’s recommendations and client agreement: Summarize the therapist’s recommendations for further treatment or interventions. Indicate whether the client agreed or disagreed with the recommendations.
13. Referrals made/reasons for making referrals: Specify any referrals made to other healthcare providers or specialists, explaining the reasons for these referrals based on the client’s needs.
14. Termination/issues relevant to the termination process: Discuss any issues related to the termination process, such as the client’s loss of insurance coverage or refusal by the insurance company to continue sessions.
15. Issues related to consent and/or informed consent: Address any matters pertaining to the client’s consent or informed consent for treatment. This may include obtaining consent for specific interventions or discussing any modifications to the treatment plan.
16. Information concerning abuse reporting: If there is evidence or suspicion of child abuse, elder abuse, or abuse of a dependent adult, document where the abuse was reported as required by law.
17. Clinical judgment: Reflect on the therapist’s exercise of clinical judgment throughout the therapy process. Discuss decisions made based on professional expertise and experience.
Part 2: Privileged Note
A privileged psychotherapy note, which would not typically be included in the client’s progress note or clinical record, should include the following information:
1. Personal reflections on therapeutic progress: Include subjective impressions and observations on the client’s progress during therapy sessions. This can involve the therapist’s personal insights, thoughts, and feelings about the therapeutic process.
2. Exploration of therapist-client dynamics: Discuss the dynamics or rapport between the therapist and the client, highlighting any influential factors that may affect the effectiveness of the therapeutic relationship.
3. Countertransference or personal biases: Reflect on the therapist’s own emotional or psychological responses to the client and how these factors might influence the therapeutic process. Acknowledge and manage countertransference or personal biases appropriately.
4. Delicate or sensitive topics discussed: Note any delicate or sensitive topics that were discussed during therapy sessions which may carry significance for the client’s treatment outcomes.
5. Personal growth or challenges: Share insights into the therapist’s personal growth or challenges encountered during the therapeutic journey with the client. This may include areas of learning or areas that require further development on the part of the therapist.
6. Reflection on therapeutic techniques or interventions: Discuss the therapist’s assessment of the effectiveness of specific therapeutic techniques or interventions employed during the sessions.
Explain why the items included in the privileged note would not be incorporated into the client’s progress note:
The items included in the privileged note are more subjective and personal in nature, providing insights into the therapist’s experiences and thought processes. Since the progress note serves as a formal and objective record of the client’s treatment and progress, it should focus on objective information regarding the client’s symptoms, treatment interventions, and outcomes. The inclusion of privileged note items may not be appropriate in the progress note, as they are not relevant to the client’s clinical record.
Whether the preceptor uses privileged notes:
It is essential to inquire about the preceptor’s use of privileged notes. If the preceptor utilizes privileged notes, they may include similar information as mentioned above, providing additional insights into the therapist’s experience and perspective. However, if the preceptor does not use privileged notes, it might be due to personal preference or institutional guidelines aimed at maintaining focused and objective progress notes.
In conclusion, the progress note for a client should accurately and objectively document the client’s treatment modality, progress, treatment plan modifications, clinical impressions, psychosocial changes, safety issues, etc. On the other hand, a privileged psychotherapy note allows the therapist to include personal reflections and insights not typically included in the progress note or client’s clinical record.