Four pages of Clinical Logs of Psychiatric Patient.

APA 7 Format, Cover page needed. No reference page needed

No plagiarism

Please follow the instructions on attached samples. Guidelines attached.

Answer all questions

Three weeks logs

One and half page per week and a total of four pages.

Indicate Log 1, Log 2, Log 3

Instructions

GUIDELINES FOR CLINICAL LOGS

1.  Maintain a clinical log.  This log should be given to the clinical instructor at the end of each 50 clinical hours.  This means that you should turn in 3 logs during your clinical experience.  

2.  The log should contain psychiatric patient assessments and discussion of the following issues:

 

 Date and Times of each clinical experience during the time frame.

 Types of psychiatric patients seen.

 Your comprehensive psychiatric patient assessment should include:

▪ History, Mental Health Assessment, Diagnosis, Treatment Plan  

 and Rational for each treatment selected.

 ▪ Any treatments given.

 ▪ Interpersonal Reaction Recordings for at least one client.

3.   Reflect on your clinical experience for the past 40 hours.  

 A.  Discuss your relationship with your preceptor.  Are you fulfilling your clinical goals?  Types of interactions?  How are psychiatric NP’s being  utilized in this practice?

   B.  Evaluate your agency/clinical site.  Include information about how the site   operates.  Discuss your perceptions of practice in this site.

 C.  Discuss any factors with facilitated or presented a barrier to your role as   an NP.

D.  Self-evaluate and critique your performance during this time period.

E.  Reactions to client interactions and responses to treatment.

4.   This log will be used to assess your progress and to give you feedback on your diagnostic skills at the beginning level.  Do not hesitate to give information on areas which you feel you could have provided better care or a different type of care.  Did you miss something altogether? How did that happen?  Critique your performance during this time frame. At this level you should be able to critique your professional practice and give information about how to improve your practice.

Suggestions for Self-Evaluation of Logs:

1.  State your clinical objectives for the week.  Were your objectives met? If so how?  If not, why? Use your written clinical objectives as a guide.

2.  Discuss feelings that relate to your professional practice this week? Include at least one aspect of professional practice as an NP and one aspect of case management, risk management. 

3.  What aspects of your professional practice do you identify as strengths? 

Give specific examples that support your conclusions.

4.  What aspects of your professional practice do you identify as needing improvement?

Give specific examples to support your conclusions.

5.  What strategies will you use to improve this/these aspects of your practice?

When, where and how will you implement your strategies for improvement.

Running head: ASSIGNMENT TITLE HERE 1

4

ASSIGNMENT TITLE HERE

Clinical log: South Oaks Hospital, Amityville.

College

March 2019

Clinical log: South Oaks Hospital, Amityville

I go to south oaks hospital in Amityville every Thursdays as part of my course requirements and clinic rotation. South Oaks hospital offers various programs for children and adolescents, both as inpatient and outpatient. My preceptor John Prato NP works in an inpatient children’s unit taking care of children and adolescent aging from 5 -18. I spent my day with John Prato taking care of the children, doing mental health assessments, follow up of labs, medication adjustments and discharge planning. I follow John with his assigned patients, participate in interdisciplinary meetings, and family meetings. We conduct psycho education to both family and patients, perform initial evaluation for new admissions, and obtain collateral information from school, outpatient psychiatrist and patient family. Upon admission, an individualized treatment plan and goals for discharge are developed based upon the children’s unique needs, situation and assessment. We provide behavioral support, facilitate therapeutic rehabilitation, one to one and family sessions and psycho education. I watched the partial program for half a day on one day and I was amazed to see the follow up in there. Written below is an initial evaluation of a client that I did on March 22 nd along with my preceptor.

Patient is a 13 year old male who is admitted due to suicidal statement and huffing dust cleaner which mother believes was in an attempt to hurt himself. Patient had also been caught Thursday 1/17/19 stole mothers credit card to purchase 80 dollars of Amazon gift certificates sent to his IPhone. On interview, patient presents tense, somewhat irritable. Pt is guarded, making attempts to minimize behaviors PTA. When asked about breathing in can of computer duster, pt denies that this was a suicide attempt or an attempt to get high. Pt does endorse feeling sad, angry irritable at times and reports poor frustration tolerance. Patient admits to punching walls, destruction of property, and physical aggression towards others. Patient denies feeling depressed, hopeless. He denies HI/SI/I/P/impulses for SIB and reports that text to friend of suicidal nature was in an effort to relate to this boy as he has had suicidal ideation before. No AVH. No delusions elicited. Pt reports that he as gone 24-48 hours without sleep, however no clear identifiable history of hypomanic/manic episode.

Collateral from Outpatient MD stated

Running head: ASSIGNMENT TITLE HERE 1

3

ASSIGNMENT TITLE HERE

Clinical log: Queens General Outpatient Clinic

College

02/24/19

Clinical log: Queens General Outpatient Clinic

I go to Queens General Outpatient clinic every Mondays as part of my course requirements and clinic rotation. My preceptor Nisha Pradeep NP, attends to 12-15 patients on a Mondays. Majority of patients that seek treatment do not have insurances or are illegal immigrants. Most of the patients are assigned to a therapist and they get to attend therapy sessions on the same day. For patients requiring medication, the NP or psychiatrist starts it or renews them and works collaboratively with the patient and therapist. I Co- leaded group therapy as part of the course requirement. They offer a variety of outpatient treatment options including individual, group or family therapy as well as marital and multi-family group therapy.

The following report is a write up of a patient that I took care of in the clinic. 27 year old single unemployed female, mother of a 2 year old son, with prior psychiatric h/o depression was sent to outpatient clinic from CPEP for worsening depression and anxiety. Patient described her mood as depressed and sad and reported difficulty initiating and maintaining sleep, feeling tired, loss of appetite and passive SI at times. Patient denies any plans or intent of SI. Patient reports frequent panic attacks, patient has h/o PCOS and ongoing pain related to that. She is unemployed and reports poor support system. Patient enjoys being with her son as her motivating factor to live. Patient stated that she takes Zoloft 50 mg from her primary care. Patient denied current SI/HI plan or intent. Patient reported that she has depressive symptoms as a teenager. Patient stated that she was taken to a clinic and was given Zoloft at that time. Patient also admits to cutting her wrist superficially in the past. Patient stated that it helps her relieve her emotional pain. Patient also reported h/o OD on pills as a teenager, as per her last cutting episode was prior to her pregnancy. Patient also reports sexual abuse by a family member at young age. Patient refused to talk about it any further. Patient denied any PTSD symptoms. Patient reported recurrent panic attacks (palpitation, SOB, shaking and dizziness). Patient reported getting panic attacks when she is very depressed. Denies AVH, no delusions elicited. PHQ-9 depression screening was performed and the score was 11(mild). Her Zoloft was increased to 100 mg daily and a follow up within 2 weeks was recommended. Patient was also referred to psychologist for therapy and dietitian for weight management.

Ou

1

Cases and Reflection

Name

Affiliation

Course Name

Instructor

Due Date

Cases and Reflection

Introduction

I worked with patients in a mental health private practice in California. The patients arrived in a welcoming waiting room before I attended to them. I would interview the patient using the history of present illness (HPI) and make a recommendation based on the information collected. The semi-structured nature of the questions allowed me to collect comprehensive patient data. My preceptor guided me on approaching an interview with a patient and how to leverage information from relatives.

Clinical Log #1

A baby-clinic referred a 26-year-old woman who came to the practice with her husband. She recently emigrated from Peru two years ago and delivered a baby girl two months ago. Since she moved to America, she has struggled with financial pressure. Her English is limited, and her husband acts as the interpreter. Her spouse indicated that the patient is unhappy and lacks the motivation to do anything. The spouse reported that the patient would rarely get out of bed or look after the baby and indicate that she experienced pains in her stomach. There was nothing abnormal with the patient and there was no history of mental health care.

Given that there was no psychiatric history and the patient was not on any medication, I had to change my approach to see if I could get any psychiatric history from the patient. I consulted with my preceptor about the possibility of using a more culturally sensitive assessment. Notably, I shared my concern that the patient could be suffering from postnatal depression.

My next step was to confirm the patient’s diagnosis. My preceptor advised me that a full assessment for the diagnosis may take longer due to cultural diversity. Further, he suggested that it would be helpful to use an independent translator during the assessment. During the early stages, I asked questions about the patient’s health as well as that of her baby to create a rapport and allow for the investigation of mental distress. The assessment reveals that the patient does not like her child and does not take care of her health, confirming the diagnosis. The treatment plan involved the use of sertraline as well as psychotherapy and was acceptable to the patient.

Clinical Log #2

A 38-years-old male patient who works as a plumber came into the practice with persistent worries. His general practitioners referred him to the mental health practices after admitting that he was under considerable stress during a consultation seeking to overcome his sleep problem. He expressed that he is crippled by the worries that he has not properly installed pipes, and the patient may experience a problem with the plumbing system, and water may destroy his client’s

GUIDELINES FOR CLINICAL LOGS

1. Maintain a clinical log. This log should be given to the clinical instructor at the end of each 50 clinical hours. This means that you should turn in 3 logs during your clinical experience.

2. The log should contain patient assessments and discussion of the following issues:

Date and Times of each clinical experience during the time frame.

Types of patients seen.

Your comprehensive patient assessment should include:

▪ History, Mental Health Assessment, Diagnosis, Treatment Plan

and Rational for each treatment selected.

▪ Any treatments given.

▪ Interpersonal Reaction Recordings for at least one client.

3. Reflect on your clinical experience for the past 40 hours.

A. Discuss your relationship with your preceptor. Are you fulfilling your clinical goals? Types of interactions? How are psychiatric NP’s being utilized in this practice?

B. Evaluate your agency/clinical site. Include information about how the site operates. Discuss your perceptions of practice in this site.

C. Discuss any factors with facilitated or presented a barrier to your role as an NP.

D. Self-evaluate and critique your performance during this time period.

E. Reactions to client interactions and responses to treatment.

4. This log will be used to assess your progress and to give you feedback on your diagnostic skills at the beginning level. Do not hesitate to give information on areas which you feel you could have provided better care or a different type of care. Did you miss something altogether? How did that happen? Critique your performance during this time frame. At this level you should be able to critique your professional practice and give information about how to improve your practice.

Suggestions for Self-Evaluation of Logs:

1. State your clinical objectives for the week. Were your objectives met? If so how? If not, why? Use your written clinical objectives as a guide.

2. Discuss feelings that relate to your professional practice this week? Include at least one aspect of professional practice as an NP and one aspect of case management, risk management.

3. What aspects of your professional practice do you identify as strengths?

Give specific examples that support your conclusions.

4. What aspects of your professional practice do you identify as needing improvement?

Give specific examples to support your conclusions.

5. What strategies will you use to improve this/these aspects of your practice?

When, where and how will you implement your strategies for improvement.