Assignment 2: Practicum – Assessing Client Progress

Assignment 2: Practicum – Assessing Client Progress

Upon completion of this learning module, students will be able to:

1. Assess client progress in the context of psychotherapy
2. Differentiate progress notes from privileged notes
3. Analyze the utilization of privileged notes by a preceptor

Preparation

Before engaging with the content in this learning module, it is essential to take the following steps:

1. Reflect on the client chosen for the Week 3 Practicum Assignment.
– Take some time to consider the specific client you selected for your Week 3 Practicum Assignment. Familiarize yourself with their case details and the presenting issues they are facing.

2. Review the Cameron and Turtle-Song (2002) article provided in this week’s Learning Resources.
– This article offers valuable guidance on the process of writing case notes using the SOAP format, which is crucial for effective documentation in psychotherapy.

The Assignment

Part 1: Progress Note

In this section of the assignment, you will create a progress note for the client you previously identified from your Week 3 Assignment. This progress note should adhere to HIPAA regulations and encompass the following components:

NRS-451 Healthcare Organizations Assessment

– Description of Treatment Modality: Clearly outline the treatment modality employed and evaluate its effectiveness in addressing the client’s issues.

– Progress Toward Client Goals: Assess and report the client’s progress or any lack thereof concerning the goals mutually agreed upon. Make reference to the treatment plan to indicate progress toward these goals.

– Adjustments to Treatment Plan: Detail any modifications made to the treatment plan based on the client’s progress or lack thereof.

– Clinical Impressions: Share your clinical impressions regarding the client’s diagnosis and symptoms.

– Psychosocial Information: Include any pertinent changes in the client’s psychosocial context since the initial assessment. This may encompass changes in relationships, living arrangements, employment, or other relevant factors.

– Safety Concerns: Address any safety issues that have emerged during the course of therapy, along with actions taken to ensure the client’s safety.

– Clinical Emergencies: Describe any clinical emergencies that occurred during sessions and the subsequent actions taken to manage them.

– Medications: Record any medications utilized by the client, even if you, as the nurse psychotherapist, were not responsible for prescribing them.

– Treatment Compliance: Document the client’s level of compliance with the treatment plan and interventions.

– Clinical Consultations: If any consultations with other healthcare professionals occurred, report on these collaborations.

– Therapist’s Recommendations: Outline the recommendations provided to the client, specifying whether the client consented to these recommendations.

– Referrals: Mention any referrals made and elucidate the reasons behind these referrals.

– Termination: If applicable, discuss any issues related to the termination process, such as informing the client about changes in insurance coverage or insurance company refusal to cover further sessions.

– Consent and Informed Consent: Address matters related to consent and informed consent for treatment.

– Reporting Child Abuse or Elder/Dependent Adult Abuse: If necessary, provide information concerning the reporting of child abuse, elder abuse, or dependent adult abuse and document where such abuse was reported.

– Clinical Judgment: Lastly, reflect on your clinical judgment as a therapist throughout this process.

Please ensure that your progress note excludes any information that should not be present in a discoverable progress note.

Part 2: Privileged Note

In this segment of the assignment, you will create a privileged psychotherapy note. This note is distinct from a progress note and should encompass information that would not typically be included in the client’s official clinical record.

Additionally, you should elucidate why the information contained in the privileged note is not appropriate for inclusion in the client’s progress note.

Furthermore, provide insights into whether your preceptor utilizes privileged notes and, if so, offer a description of the type of information they might include. If your preceptor does not use privileged notes, provide an explanation for this practice.

Please make use of the enclosed documentation from your Week 3 practicum, specifically the Psychiatry New Evaluation History and Physical report for the identified patient, MRN: 0000, dated 9/13/19. This information should aid you in completing the assignment effectively.

Part 1: Progress Note

Treatment Modality Used and Efficacy of Approach

In this case, the client is undergoing cognitive-behavioral therapy (CBT) to address her anxiety and other psychological challenges. CBT is a well-established psychological approach renowned for its effectiveness in treating a wide range of mental health disorders, making it a suitable choice for this particular case (Kaczkurkin & Foa, 2015).

Progress

The client has exhibited significant progress in managing her anxiety and thought patterns. She has successfully identified her anxiety triggers and acquired valuable skills in breathing and relaxation techniques, as well as other non-pharmacological interventions. Over the course of treatment, her symptoms of depression and anxiety have markedly decreased.

Modifications

Modifications to the treatment plan were minimal, primarily due to the client’s cooperative and motivated attitude towards improvement. Exploring the possibility of family therapy has the potential to positively influence the family members’ attitudes and provide essential social support by fostering a deeper understanding of her situation (Jadav & Sharma, 2018).

Clinical Impressions

The client’s symptoms encompass poor academic performance, exemplified by her struggles in the nursing class. Her mood has been consistently moderately dysphoric, accompanied by difficulties in concentration, negative thoughts, low self-esteem stemming from previous academic setbacks, diminished interest in activities, feelings of insignificance, low energy levels, and severe impairment in concentration and psychomotor function (Gazzillo, Dimaggio & Curtis, 2019). Additionally, she experiences heightened worry and muscle tension.

Psychosocial Information

The client is a nursing student without current employment. She is not married but is in a relationship with a partner who does not support her academic pursuits. She resides with her family, which does not provide the necessary social support and holds the belief that she should have pursued a different major. None of her family members have attended college.

Safety Issues

The client’s condition presents potential safety concerns related to self-harm and suicidal thoughts, often associated with depression (Bruns & Letcher, 2018). Additionally, her social drinking on weekends poses the risk of exacerbating her mental and physiological condition, possibly leading to substance abuse.

Clinical Emergencies

No clinical emergencies have arisen in connection with the patient’s condition.

Medications

The client is not currently prescribed any medications, either by a healthcare professional or through self-administration.

Treatment Compliance

The patient has consistently adhered to the treatment plan as prescribed. She has shown determination in seeking counseling and actively participating in cognitive-behavioral therapy (CBT) to facilitate her recovery. By the third week of CBT, she had taken steps to identify her stressors, record dysfunctional thoughts, and develop healthier thought patterns for practical implementation.

Clinical Consultations

Clinical consultations have been conducted through various means, including phone calls, emails, and messaging. The client has also made in-person visits to the clinic for follow-up appointments with the psychiatrist.

Collaboration with other Professionals

The treatment approach involved collaborative efforts between the psychiatrist, physical therapist, physician, and family therapist. This collaborative approach facilitated ongoing monitoring of the client’s progress, the development of appropriate CBT interventions, and the active involvement of the client’s family in the treatment plan (Tzur Bitan & Lazar, 2019).

Therapist’s Recommendations

The therapist’s recommendations encompass the importance of maintaining compliance and consistency with CBT, as well as fostering positive thought processes. It is noteworthy that the client fully agreed with these recommendations.

Referrals

No referrals were deemed necessary, as the client responded exceptionally well to the established treatment plan.

Termination/Issues

The client’s decision to terminate the sessions was unscheduled and stemmed from her rapid and positive recovery within a relatively short period. Financial constraints related to her lack of employment and insufficient insurance coverage to sustain continued attendance were contributing factors to her decision.

Informed Consent, Child Abuse, and Therapist’s Exercise of Clinical Judgment

The client provided informed consent for her treatment plan. The practitioner ensured that the client received comprehensive information about her condition, the proposed treatment plan, and the anticipated consequences. This adherence to informed consent aligns with the guidelines outlined in psychiatric nursing practice.

Abuse

The client has not reported any incidents of child or elder abuse.

Therapist’s Exercise of Clinical Judgment

Clinical judgment was exercised based on a thorough evaluation of both objective and subjective information obtained from the client. Consequently, the clinical judgment process involved informed and collaborative decision-making, with active engagement from both the client and the therapist.

Part 2: Privileged Note

A privileged note was employed for the purpose of documenting and analyzing the content of therapeutic sessions. This note serves as a foundational outline of the topics covered during these sessions. Notably, the privileged note omits specific details such as session initiation and conclusion, treatment frequency and modalities, clinical test results, diagnostic information, prescription medication details, and progress note summaries.

The rationale behind excluding these elements from the privileged note is to maintain the clear distinction between the privileged note and the progress note. Typically, privileged notes serve as repositories for information that is not included in the official clinical record. The omission of these details helps protect the sensitive and confidential nature of the patient’s information, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Regarding the preceptor’s practices, privileged notes are utilized to document conversations that occur during therapy sessions with patients. These notes capture observations made during the sessions, the therapist’s thoughts and emotions regarding the patient’s psychiatric diagnosis hypothesis, and the unique aspects of the patient’s condition. While the preceptor utilizes privileged notes for documentation and analysis, it is worth noting that these notes do not adhere to a specific format.