Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the “Discharge Summary” template.
Part 2: Write a 700-1,050-word summary statement about your client, Eliza.
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Include or address the following in your summary statement:
- Demonstrate whether or not the client met the goals of the treatment plan.
- What specifically contributed to the success of the treatment plan or lack thereof?
- What language would you use to communicate the outcome to the client?
- How would you document the final session?
- Include at least three scholarly references in your paper.
Submit your discharge summary and summary statement to your instructor.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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1
Running Head:
Treatment Plan
6
Treatment Plan
Treatment Plan
Jennifer Rizzo
Grand Canyon University
03/20/2021
Part 2
Despite Eliza going through treatment and having a period of sobriety, she has started drinking again, according to the incident report that indicated she was found passed out and alone in her dorm while smelling of alcohol. The changes in Eliza’s behavior of drinking alcohol may have been caused by various factors such as boredom, changes in finances, being exposed to alcohol, having unwanted emotions related to certain situations, and being with friends with who she used to drink. In early recovery, boredom and isolation are considered to be the major reason for relapse. She might have got bored or felt isolated, which left her with her own thoughts and emotions that usually do not want to be heard or felt. Poor self-care may have also caused her alcohol relapse because proper self-care always makes one feel better about themselves, and it will be sending a message to them that they care about their wellbeing. Poor self-care sends messages to a person that they do not care about their wellbeing, which triggers a relapse.
An effective treatment plan is usually made up of key components which allow the therapist to create an accessible and easy-to-use document with all the information that the client and therapist will need. When assessing the effectiveness of a treatment plan, some factors must be considered, such as progress, interventions, objectives, goals, treatment contract, strengths, problem statements, and the client’s history and background (Sripada, et al., 2020). Documentation of the client’s progress is among the important factors to be considered in a treatment plan. As treatment of the client progresses, it is necessary to look back on the past successes because they offer a great source of inspiration to stay on course. However, looking at Eliza’s progress, she has gotten back into abusing alcohol which is negatively affecting her. Another element of an effective treatment plan is the history and background of the client. This section usually has important demographic information about the patient’s past, present, and when she started experiencing the problem.
The treatment plan needs to be adjusted to deal with changes in the situation by using various strategies like client involvement, writing down outcomes at different intervals, offering support to the client, promoting active participation, and setting clear goals. For a treatment plan to be effective, it must start with clear goals by determining what the client would like to work on. Having clear goals ensures that the client is on the same page with the therapist, and it keeps both of them accountable for concentrating on what is necessary. The treatment plan should involve active participation to showcase how every party will work to achieve the goals. Active participation will help since it will open up a great discussion about the role of a counselor and how therapy looks with the client.
I would communicate to the client the need for referrals to other behavioral health care professionals when there are ethical concerns about working with an individual and believe that somebody else will be able to provide a more suitable service and when there is a change in an individual’s social, emotional and physical situation. Other instances may include when the therapist is concerned about the client’s emotional, social and physical state, when the agency does not provide all the services that the client requires, and when a client asks the therapist to refer them (Broglia, Millings, & Barkham, 2018). Making a referral involves certain steps like finding the problem, evaluating the data, identifying and assessing possible resolutions, identifying additional information that is required, and then finally making the referral. When making a referral for the client, one should keep their connection with their client till the referral process is complete, help prepare the client for their first appointment and allow the client to make the appointment instead of making it for them. The therapist should also be aware of confidentiality issues, explore with the client where she might have sought assistance, explore the readiness of the client to be referred, knowing the agency or person to whom they are making the referral, and ensure they understand what policies and procedures the agency has for making referrals.
The referral that I would make is referring the client to alcohol and drug treatment experts for a more in-depth and definitive assessment. I would collaborate with other behavioral health care professionals by practicing handling conflicts and striving towards perfection, assigning specific responsibilities and tasks, delegating the duties of every member of the team, respect job roles, and define my collaborative approach to health care. In order to collaborate with other behavioral health care professionals, I would learn to appreciate the roles and responsibilities of other specialists for us to work efficiently as a group since the success of any group greatly depends on providing quality treatment of patients. I will define the roles of the professionals’ history, what their actual job title is and also define them on how they will help other patients in dealing with the current issues. Every health care provider is required to establish a system of feedback to make sure that the tasks are accomplished, identify guidelines for reducing risks related to the delegation, determining the level of supervision required to help support delegation in health care and educate others on effective judgment for task analysis and resolutions to delegate (Morley, & Cashell, 2017). Collaborating with other behavioral health care professionals who have diverse viewpoints and areas of expertise will result in new perceptions and resolutions to problems that hardly get achieved by a single health professional. Collaboration with diverse groups is vital for the continued development in my specialization; hence it is necessary to educate and practice on how to deal with various issues.
Some of the ways that I would assess the client include screening and testing. Alcohol screening tests will help to determine if the client still abuses alcohol or has any alcohol use disorder. Alcohol screening comprises behavioral and psychological questionnaires, while alcohol testing entails testing of saliva, breath, and blood to detect the quantity of alcohol in the client’s body system (Clark, et al., 2016). Physical testing for the availability of alcohol in the bloodstream will play a key role in finding whether the client who is undergoing treatment for alcoholism is complying with her plan for recovery.
Reference
Broglia, E., Millings, A., & Barkham, M. (2018). Challenges to addressing student mental health in embedded counseling services: a survey of UK higher and further education institutions. British Journal of Guidance & Counselling, 46(4), 441-455.
Clark, B. J., Rubinsky, A. D., Ho, P. M., Au, D. H., Chavez, L. J., Moss, M., & Bradley, K. A. (2016). Alcohol screening scores and the risk of intensive care unit admission and hospital readmission. Substance abuse, 37(3), 466-473.
Morley, L., & Cashell, A. (2017). Collaboration in health care. Journal of medical imaging and radiation sciences, 48(2), 207-216.
Sripada, R. K., Ready, D. J., Ganoczy, D., Astin, M. C., & Rauch, S. A. (2020). When to change the treatment plan: An analysis of diminishing returns in VA patients undergoing prolonged exposure and cognitive processing therapy. Behavior therapy, 51(1), 85-98.
CNL-610: Topic 8 Discharge Summary Template
Directions: Complete the Discharge Summary form by addressing the fields below.
Client Name: Click or tap here to enter text.
Date of Birth: [MM/DD/YYYY]
Date of Admission: [MM/DD/YYYY]
Date of Discharge: [MM/DD/YYYY]
Presenting Problem Upon Admission: [State the client’s presenting problem upon admission. What behaviors would indicate that the client is sustaining at a healthy baseline or the presenting problems are no longer an issue?]
Click or tap here to enter text.
Current Medication: [List the client’s current medications, if applicable.]
Click or tap here to enter text.
Reason for Discharge: [State the client’s reason for discharge. How did you determine if Eliza met her treatment goals?]
Click or tap here to enter text.
Resources and Referrals: [List the client’s resources and referrals. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services?]
Click or tap here to enter text.
Projected Prognosis: [State the client’s projected prognosis.]
Click or tap here to enter text.
Eliza D 00/00/00
Client Signature & Date
Counselor’s Signature & Date
© 2019. Grand Canyon University. All Rights Reserved.
Rubic_Print_
| Format |
| Course Code |
Class Code |
Assignment Title |
Total Points |
| CNL-610 |
CNL-610-O500 |
CNL-610 Discharge Summary and Summary Statement (Obj. 8.1 and 8.2) |
100.0 |
| Criteria |
Percentage |
Unsatisfactory (0.00%) |
Less Than Satisfactory (74.00%) |
Satisfactory (79.00%) |
Good (87.00%) |
Excellent (100.00%) |
Comments |
Points Earned |
| Content |
70.0% |
| Part 1: Discharge Summary |
30.0% |
Discharge Summary omits or incompletely describes the client’s presenting problem upon admission, current medication, reason for discharge, resources and referrals, and projected prognosis.Discharge Summary does not demonstrate understanding of the topic. |
Discharge Summary inadequately describes the client’s presenting problem upon admission, current medication, reason for discharge, resources and referrals, and projected prognosis, but description is weak. Discharge Summary demonstrates a poor understanding of the topic. |
Discharge Summary adequately describes the client’s presenting problem upon admission, current medication, reason for discharge, resources and referrals, and projected prognosis, but description is limited. Discharge Summary demonstrates a basic understanding of the topic. |
Discharge Summary clearly describes the client’s presenting problem upon admission, current medication, reason for discharge, resources and referrals, and projected prognosis, and description is strong. Discharge Summary demonstrates an understanding that extends beyond the surface of the topic. |
Discharge Summary expertly describes the client’s presenting problem upon admission, current medication, reason for discharge, resources and referrals, and projected prognosis, and description is comprehensive and insightful. Discharge Summary demonstrates an exceptional understanding of the topic. |
| Part 2: Summary Statement |
40.0% |
Summary Statement omits or incompletely describes whether or not the client met the goals of the treatment plan, what contributed to the success of the treatment plan or lack thereof, what language you would use to communicate the outcome to the client, and how you would document the final session.Summary Statement does not demonstrate understanding of the topic. |
Summary Statement inadequately describes whether or not the client met the goals of the treatment plan, what contributed to the success of the treatment plan or lack thereof, what language you would use to communicate the outcome to the client, and how you would document the final session, but description is weak and missing evidence to support claims. Summary Statement demonstrates a poor understanding of the topic. |
Summary Statement adequately describes whether or not the client met the goals of the treatment plan, what contributed to the success of the treatment plan or lack thereof, what language you would use to communicate the outcome to the client, and how you would document the final session, but description is limited and lacks some evidence to support claims. Summary Statement demonstrates a basic understanding of the topic. |
Summary Statement clearly describes whether or not the client met the goals of the treatment plan, what contributed to the success of the treatment plan or lack thereof, what language you would use to communicate the outcome to the client, and how you would document the final session, and description is strong with sound analysis and some evidence to support claims. Summary Statement demonstrates an understanding that extends beyond the surface of the topic. |
Summary Statement expertly describes whether or not the client met the goals of the treatment plan, what contributed to the success of the treatment plan or lack thereof, what language you would use to communicate the outcome to the client, and how you would document the final session, and description is comprehensive and insightful with relevant evidence to support claims. Summary Statement demonstrates an exceptional understanding of the topic. |
| Organization and Effectiveness |
20.0% |
| Thesis Development and Purpose |
7.0% |
Paper lacks any discernible overall purpose or organizing claim. |
Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear. |
Thesis and/or main claim are apparent and appropriate to purpose. |
Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose. |
Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis. Thesis statement makes the purpose of the paper clear. |
| Argument Logic and Construction |
8.0% |
Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. |
Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. |
Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. |
Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. |
Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. |
| Mechanics of Writing (includes spelling, punctuation, grammar, language use) |
|
| 5.0% |
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. |
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. |
Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. |
Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. |
Writer is clearly in command of standard, written, academic English. |
Format
| 10.0% |
| Paper Format (use of appropriate style for the major and assignment) |
5.0%
Template is not used appropriately or documentation format is rarely followed correctly. |
Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. |
Appropriate template is used. Formatting is correct, although some minor errors may be present. |
Appropriate template is fully used. There are virtually no errors in formatting style. |
All format elements are correct. |
| Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) |
5.0%
Sources are not documented. |
Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. |
Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. |
Sources are documented, as appropriate to assignment and style, and format is mostly correct. |
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. |
| Total Weightage |
100% |
