Assessing Client Progress
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 profile below
- Review the Cameron and Turtle-Song (2002) article in the Learning Resources for guidance on writing case notes using the SOAP format. (Template uploaded)
The Assignment
N/B: PLEASE Addressed each of the bullets with a subtopic, please you can add other good references related to the assignment. All must be cited as an in-text citation in each paragraph. If you have to use other articles, they must be within last five years only that is from 2014 to 2018.
Part 1: Progress Note
Using the client profile below, 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 profile below.
Addressed each of the bullets with a subtopic
- 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.
REFERENCES
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.
- Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)
- Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)
Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4
U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/
Required Media
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.
Note: For this week, view Reality Therapy, Feminist Therapy, and Solution-Focused Therapy only.
Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.
The approximate length of this media piece is 110 minutes.
Client profile that must be used to write the above paper (you can add information that might be useful to make the story flow)Please do not copy and paste client profile to SOAP note(Plagiarism)
: Comprehensive Client Family Assessment
Demographic information: This covers the characteristics of a population. Some of the characteristics examined are race, ethnicity, gender, age, education, profession, occupation, income level and marital status (Mabey, 2015). Juan Hernandez is a 45-year-old Mexican male a married to Elena Hernandez who is also a 43-year-old Mexican lady. (Not real client names)
Presenting problem: This refers to the initial symptoms that lead someone to seek help from a doctor or other provider (American Psychiatric Association, 2013). The Juan Hernandez as the head of his family is seeking counseling to address his frustrations and worries he experiences, parenting his children. He is accompanied by his wife Elena who is encouraging him to seek help because she is stressed out as well. He expressed feeling anxious, depressed, and angry most times which makes him harsh to his children. He is also worried that he might have inherited some traits from his parents on hard parenting methods.
History or present illness: Juan Hernandez reports having an anger outburst since middle school which was never evaluated and treated because it was “normal” for his family. He reports that the feelings resurfaced after he started feeling stressed out and frustrated with his children. They have no serious, severe illness as well.
Past psychiatric history: Juan Hernandez has never been diagnosed with any mental health problem.Hence, the client has had no case of mental illness other than the current instance of uncontrolled anger, anxiety, and depression. His wife Elena has no mental health history.
Medical history: Juan Hernandez was recently diagnosed with hypertension and he reports that his father is hypertensive as well. Elena his wife has no medical problems.
Substance use history: Juan Hernandez denies any use of illegal drugs. There are no substance use incidences in the past of Juan or Elena.
Developmental history refers to a person’s growth. Both clients have not reported any case of developmental complications. Juan and Elena were born full term and grew normally.
Family psychiatric history refers to cases of any mental illness in the family and relatives of the clients. Juan has not reported any cases of family psychological history. Despite the fact that Juan’s parents were hard on him with angry tones most times, they were never diagnosed with mental health problems. Elena as well has not reported any case of family physiological history.
Psychosocial history, this is the client’s background on matters relating to the interrelation of social factors and individual thought and behavior. Juan is a construction worker and has few friends that he chats with occasionally.
History of abuse/trauma refers to cases of repeated treatment of an individual in cruelty or violence (Wheeler, 2014). Juan has had instances of trauma out of violence treatment from both his parents. This made him hate schooling and hence become severely affected. Something that he is worried might happen as well to his family. Elena expresses no history of trauma.
Review of systems, this is a technic used by healthcare providers for eliciting a medical history from a patient (Mabey, 2015). Juan reported general fatigue and difficulties sleeping at night. Neurologic; dizziness sometimes. Gastrointestinal: decreased appetite and constipation. Psychiatric; stress and depression. Elena ROS; General: Neurologic: No issues reported. Gastrointestinal heartburn and constipation
Physical assessment refers to the structured examination perform by any health provider to collect the complete data about a patient. In this assessment, the provider used observation, inspection, palpation, auscultation, and percussion. Juan proved to be physically fit and no case of complications as well as Elena.
The mental status exam is the evaluation of the individual’s current mental capacity through the evaluation of general appearance, behavior, any great belief and perception, mood and all aspects of cognition. Juan is alert, and oriented x3, neatly groomed, has appropriate affect and mood, speech clear and coherent and sufficient cognition noted. No sign of abnormality noted. Elena’s mental state also proved to be fit as well. Juan and Elena deny suicidal and homicidal ideations.
Differential diagnosis, this refers to the process of distinguishing a particular disease or disorder from the others that share similar clinical features. Juan was evaluated to have generalized anxiety with anger symptoms, a Depressive disorder associated with insomnia and decreased appetite, and lastly hypertension.
Case formulation means problems formulation that involved a theoretically based explanation of the information obtained from a clinical assessment (Mabey, 2015). Juan presented a problem of being too angry, and this problem was contributed by trauma that he had as a child from his parent’s punishment when they were angry. The client has been in this state by repetition of the same situations. The client has access to the medical care as a way of accessing health. Elena presented her situation as being stressed by Juan actions and fearful attitudes of their children.
Treatment plan involves guidelines for helpful ways of ensuring that the client has been saved from the disorder shown (Young, & Solomon, 2009). Juan is an intelligent man the clinic will support him by offering psychoeducation. The interventions involve talk therapy, client will explore feelings and coping skills in life situations, explore measures of self-control and remain safe, be able to express self calmly without anger, develop holistic self-care to manage life stressors, explore his experiences and how they impact his relation to himself and others and how it contributes to experienced anxiety and, explore sleep hygiene ways to improve sleep. Juan and Elena will explore helpful and good parenting strategies to help guide their children upbringing.
References for client profile above
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author.
Mabey, L. (2015). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-to Guide for Evidence-Based Practice. Journal of EMDR Practice and Research, 9(1), 71.
Waters, I., Watson, W., & Wetzel, W. (2014). Genograms. Practical tools for family physicians. Canadian Family Physician, 40, 282.
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.
Young, J. M., & Solomon, M. J. (2009). How to critically appraise an article. Nature Reviews Gastroenterology and Hepatology, 6(2), 82.
