Part 1: Progress Note

Using the client family from your Week 3  Practicum Assignment, address in a progress note (without violating  HIPAA regulations) the following:

  • Treatment modality used and efficacy of approach
  • Progress and/or lack of progress toward the mutually agreed-upon  client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move  to a new house/apartment, change of job)
  • 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
  • The 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  (e.g., 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  family from the Week 3 Practicum Assignment.

In your progress note, address the following:

  • 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 family’s progress note.
  • Explain whether your preceptor uses privileged notes. If so,  describe the type of information he or she might include. If not,  explain why.

Running head: ASSESSING CLIENT PROGRESS
1

ASSESSING CLIENT PROGRESS

8

Practicum Assessing Client Progress

Name

University

Part 1: Progress Note

The patient selected in week 3 was J.J, a 27 year-old African American female who presented symptoms of- and diagnosed with moderate post-partum depression (PPD).

Treatment modality used and efficacy of approach

The treatment modality used is Cognitive Behavioral Therapy (CBT) and support groups. CBT is a talk psychotherapy which aids in modifying a patient’s negative behaviors, thoughts, attitudes, as well as emotional response associated with psychological distress (Huang, Zhao, Qiang, & Fan, 2018). CBT is highly effective in helping patients suffering PPD which is mental health disorder characterized by onset of negative thoughts, attitudes, behaviors and emotional responses related to stress that comes with new born responsibilities (Huang et al., 2018).

Support group on the other hand involves interaction with others going through the same situations. It is highly crucial for individuals with PDD symptoms to seek support as it significantly contributes a lot in lifting the fog of PDD and keeping it far away (Morikawa et al., 2015). Isolation and loneliness usually worsen depression as patients that stay on their own find it considerably difficult to maintain and sustain perspective and effort needed to deal with depression. As such, it is highly crucial for PDD patients to maintain close relationships as well as social activities to be able to cope with their health situation (Morikawa et al., 2015).

Progress and/or lack of progress toward the mutually agreed-upon client goals

From assessing the patients progress, the agreed upon goals were met. The therapy significantly improved the patient’s stress, anxiety, and depressive symptoms. The scores in PHQ 9 mental test reduced from 10 to 5 in four weeks of check up and from 5 to 2 in eight weeks. The patient’s symptoms had improved in that, at the 4th week the patient reported positive effects of the treatment. She had employed a nanny to help her with the babies and thus felt less fatigued and full of energy in the morning. More so, she managed to improve on her sleeping patterns as she would sleep at night when the babies slept. Patient further reported that her support group was very helpful and it helped a lot in dealing with her feelings of hopelessness, helplessness, and worthless. In addition, the patient no longer had suicidal ideations and was excited about taking care of her newborns. These are key indicators of the efficacy of the treatment modalities used as well as positive progress of the patient.

Modification(s) of the treatment plan that were made based on progress/lack of progress

Due to the observed and reported effects of CBT and support groups in deal

Practicum Experience Time Log and Journal Template

Student Name: Semiloore Akerele

E-mail Address: [email protected]

Practicum Placement Agency’s Name: Lincolnwood medical center

Preceptor’s Name: Dr Syed Rahim

Preceptor’s Telephone: 8472874505

Preceptor’s E-mail Address:[email protected]

Comprehensive Client Family Assessment

Semiloore Akerele

Walden university : PRAC- 6650

Comprehensive Client Family Assessment

Demographic Information

Robin is an employed African American female who is 60 years old and is married to her husband of 50 years and they have been married for 15 years. She has three sons and one of them was killed. Robin is referred for stress-related concerns by her employer’s Employee Assistance Program.

Background Information

Identification:

Robin is a Christian she goes to church every Sunday.

History of Present Problem:

Robin states that she needs help as she feels like she is always taken advantage of. This has left her feeling angry most of the time and wondering whether she is just a piece of garbage. Various compiled reasons make her cry up to about five times each week. The stress makes her feel sleepy and tired most of the time and she feels like she is alone and does not have anyone. She also spends a lot of time overthinking about her husband’s issues and his drama. The husband cheated on her and she has been struggling with letting go of the pain and moving past infidelity. Her husband also snorts heroin and this leaves Robin to take care of their financial responsibilities. Robin asked her husband to move out and she has been able to sleep for at least 6 hours since then, compared to the 4 hours she was getting before. Robin admits to gaining weight during the months of winter and being a stress eater.

Past Psychiatric History:

Robin was at the psychiatrist for marital issues in the last 3 months.

Medical History and Conditions:

Thyroid complications of the esophagus.
-Back surgery in 2016.

-Neck disc complications
-Total knee surgery on the right knee in 2017.
-Identified with stage one breast cancer on 2/2019 and had a lumpectomy in June and July 2019.
-Diagnosis identified tendinitis in her left foot.
– Has stomach ulcers.

Current Medications:

-Lisin0pril

-Gabapentin (nerve pain)
-Oxycodone 10mg as needed for pain

Substance Use History:

-Alcohol- first used at 12 years of age and last used on 7/7/19. Characteristically consumes approxima