Learning Objectives

Students will:

· Assess progress for clients receiving psychotherapy

· Differentiate progress notes from privileged notes

· Analyze preceptor’s use of privileged notes

To prepare:

· 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.

The Assignment

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.

4

ASSESSINGCLIENT PROGRESS

Assessing Client Progress

NURS 6640

Walden University

Progress Note

Client Name: JS

Diagnoses (DSM-5): Major depression disorder, recurrent, moderate severity with schizophrenic episode.

Date: 10/13/18

The patient was presented to the day center with signs and symptoms of depression with schizophrenic behavior and use of illicit drugs in the past, therefore the use of behavior modification treatment approach will be beneficial. The Cognitive behavioral therapy (CBT) will be the best treatment because it helps in assisting the patient, on how he/she views himself or herself, the problem, and the available resorts (Wheeler, 2014, p.329). The incorporation of cognitive therapy was effective because there was decrease in schizophrenic behaviors and, also in depressive moods, thus, led to progress in patient’s goals by mutually accepting the treatment plan ahead in medication adjustment and some exercises. Few modifications were made during treatment, such as exercising, eating healthy meals and taking medication at appropriate time. No relevant psychosocial information or changes from initial assessment. Patient has not had any current clinical emergencies, indicating diagnosis and treatment of disorder is managed.

The patient is currently on antipsychotic medication which is effective and, a reconsideration of putting him on Selective Serotonin Reuptake Inhibitor (SSRI) to manage his depression, which was helpful in the past. This medication has seen to help in decreasing patient’s psychotic behaviors and therapist in collaboration with the Psychiatrist in putting him on SSRI regimen. With the assistance of his mom and caregivers, patient is complying with treatment and improvement in symptoms is seen. So engaging patient more in cognitive therapy will assist in bringing self-worth to the patient and ensuring effective management of care.

Privileged Note

In a privileged note, it encloses information regarding a patient during their individual/group sessions, assessments and treatment options and plans. Obtaining and documenting the informed consent in lure of the professional relationship between the therapist and patient diagnosed with major depressive disorder, recurrent, severe moderate severity with schizophrenic episode is usually processed through recording. Here any private counseling session, or a group, joint or family counseling sessions are separated from the patient’s primary medical record because is not a progress note, it only assists the therapist in organizing himself/herself in treating the patient (TheraNest Staff, 2018). Privilege Notes sometimes consist of the psychotherapist hypotheses, observation, questions or any thoughts or feelings relating to the therapy session (2018).

Again, all items seen in privilege notes should not be in medical records because it is only for the therapist use. During my clinical rotation, my preceptor did make use of privilege notes in which she asked the patient how their last session was, and what he would need from her to better manage his prognosis that will lead to an effective treatment plans.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

The Differences Between Psychotherapy Notes and Progress Notes. (2018, September 18). Retrieved October 12, 2018, from https://www.icanotes.com/2018/06/08/the-differences-between-psychotherapy-notes-and-progress-notes/

TheraNest Staff. (2018, June 11). What are Psychotherapy Notes vs Progress Notes? Retrieved October 12, 2018, from https://www.theranest.com/blog/what-are-psychotherapy-notes-vs-progress-notes/

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

1

Demographic Information:

Client is a 48 years old African American Male, divorced, currently jobless and living in a one bedroom basement rental. Has been seen in this office on and off for about a year now. Patient was sexually molested by a family member at age nine and infected with HIV which has significantly affected his normal life function leading to Major Depression. He presents with frequent episodes of Anxiety attacks during this visit stating; “I need help controlling my emotions.”

Presenting Problem: Frequent Anxiety attacks with severe depression due to increased fatigue preventing patient from being able to keep a job.

History of Present illness: He suffers frequent Anxiety attacks because he has lost his job and cannot afford basic necessities. Application for financial assistance was declined and he is stressed over poor living condition. He is unable to control his mood and being rude to everybody.

Past Psychiatric history: Has suffered with depression, mood problems and physical problems since age 9 and has been in therapy at different points over the years.

Medical History: Has a history of HIV and in compliance with medication regimen. Has no known drug allergies. Currently on Klonopin 2mg and Abilify 2mg at bed time, Effexor XR 150mg daily and Remeron 30mg at bedtime.

Substance use History: No alcohol or illicit drug use

Developmental History: Client lost single mother at age five and was raised by grandmother thereafter. He was sexually molested at nine after which he started performing poorly in school and got in a lot of disciplinary situations. He was locked up in a Juvenile center at age 15 for constant fights wherever he went. He was married for 3 years and his wife filed for divorce of his bad temperament most of the time He appears well nourished and groomed.

Family Psychiatric history: Client states he was told his mother died of illicit drug overdose-unspecified. Grandmother was an alcoholic and verbally abusive; and he never knew his father. Paternal family and both sides of family Great-grandparents’ history is unknown.

Psychosocial History: Client is divorced, lives alone and has lost friends because of mood instability

History of abuse/Trauma: He was sexually molested and infected with HIV by a family member at age nine.

Review of Systems:

General: Client appears well nourished, well hydrated, no acute distress, is well dressed and groomed. Client complains of losing more hair, denies any vision or hearing problem.

Psychiatric: Speech is normal. Coherent and goal oriented. Thought blocking, intermittent flight of idea and looseness of association.

Abnormal thoughts: Passive suicidal ideation.

Judgment and insight: Intact

Mental Status Examination

Orientation: Alert and oriented x 3 to person, place and time.

Memory: Intact for recent and remote events.

Attention: Attends to task normally

Differential Diagnosis:

Major Depressive disorder: This is a serious debilitating condition plaguing public health and considered of very high prevalence. (Kupfer, Frank, & Phillips, 2016). Depression can be worsened by presence of comorbidities like this client who is also dealing with HIV. Also the presence of Anxiety and depression concurrently like in this client can lead to a misdiagnosis which explains why some researchers are pushing for “anxious depression,” to be added as a diagnosis for easy identification in DSM-5. (Kupfer, Frank, & Phillips, 2016). Major depressive disorder could be triggered by traumatic life events with an onset during childhood, recurring over years to adulthood and could lead to self-harm and suicide if not diagnosed and managed appropriately, (Saddock et al. 2019). The client has suffered from depression since childhood trauma and has passive suicidal ideation requiring proper treatment.

Case Formulation:

This client presents with frequent Anxiety attacks seeking help to control mood and ways to minimize anxiety. Attacks are triggered because of recent loss of job, no financial support and at risk of losing accommodation which already is not ideal. He is depressed, in a bad mood most of the time causing him to be unable to interact normally and maintain relationships. Goals, beliefs and aspirations would be explored for positive enforcement and direction.

Treatment Plan

He is aware of his relapse and the fact that he needs help and is willing to follow a treatment plan with medications and CBT to identify healthy ways of dealing with stressful situations and expressing feelings. Combining both therapy and medication regimen has been proven to be of greater success. (Corey & Cengage Learning (2013). Community resources would also be exploited for physical and psychosocial assistance. Client is compliant with medications regimen thus far which is a very important part of treatment plan as 40% of patients have been proven to suffer due to non-compliance. (Martin, Williams, Haskard, & Dimatteo, 2005).

References

Corey, G., & Cengage Learning (Firm). (2013). Theory and practice of counseling and psychotherapy: The case of Stan and lecturettes. Belmont, CA: Brooks/Cole Cengage Learning.

Kupfer, D. J., Frank, E., & Phillips, M. L. (2016). Major Depressive Disorder: New Clinical, Neurobiological, and Treatment Perspectives. Focus, 14(2), 266–276. doi: 10.1176/appi.focus.140208

Martin, L. R., Williams, S. L., Haskard, K. B., & Dimatteo, M. R. (2005, September). The challenge of patient adherence. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/.

Sadock, B. J., Ahmad, S., & Sadock, V. A. (2019). Kaplan & Sadock’s pocket handbook of clinical psychiatry.