Progress Note on Client
Create progress notes
Create privileged notes
Justify the inclusion or exclusion of information in progress and privileged notes
Evaluate preceptor notes
To prepare:
Reflect on the client family you selected for the Week 3 Practicum Assignment.
Assignment
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.
Progress Note
Name
Institution
Due Date
Progress Note
Name of Patient:
Date:
Subjective
A.M. suffers from suicidal tendencies, which is a reflection of mental distress resulting from living in a disjointed family. The parents separated owing to the father’s behavior of having an affair with the aunt. A.M. feels guilty of not informing the mother of the affair earlier enough despite having knowledge of the affair. The experiences from such a family environment and the loss of her child have made her develop post-partum depression alongside being angry most of the time and feeling wasted. There are clear signs showing deterioration of his health, resulting in loss of weight due to malnutrition.
I have ensured that I scan through his past medical history to establish any medications that she has undergone in the past. Further, I have made an adequate inquiry on family life, including social history that may have contributed to her current condition. She recovered from post-partum depression, and her medical history indicates that she recovered from influenza without any physical trauma. She has a history of being an occasional alcoholic beverage drinker as well as smoking cigarettes and marijuana.
The client confirms her worries, especially concerning the state of the family impacted by her father’s moral behavior. The boy is a teenager and attending school. Therefore, the client believes that he may not receive many benefits from the therapy. The same applies to his wife, always busy at work as well as undertaking house chores during the evening hours. However, all members of the household must attend the therapy sessions for purposes of realizing optimal results. Consequently, Cliff suggests that supportive therapy may be more beneficial to him than family therapy sessions due to the nature of the illness he currently suffers from.
Objective
The findings upon physical examination reveal that A.M. has no signs of abuse or trauma types. Never suffered any bullying process before. However, she appears to be in a depressed mood and shows positive signs of post-partum depression as well as suicidal tendencies.
A.M. recorded weight loss due to loss of appetite. She has normal BP, PR, and temperature normal. She avoids eye contact but very cooperative and answers questions appropriately. She is slow in thinking but right perception with a good memory.
Assessment
A.M. is a 25-year-old Caucasian female patient currently having suicidal tendencies. The therapy processes that he has been taken through has proved productive. The client, A.M., is very cooperative, therefore, experiencing tremendous improvement. A.M. is open to discussing why she considers her spouse to be brutal and the possibility of changing. The level of suicidal thoughts and anger had significantly reduced compared to when we started the first sessions.
Notably, the client ensured that she remains calm throughout the sessions. There were instances where the client made good remarks concerning various steps taken towards improving her condition. Despite experiencing some challenges during the processes, there was a clear demonstration of high-level satisfaction as well as willingness to complete therapy sessions. However, she assures on her efforts to overcome any attempt to withdraw from the current therapy sessions.
Despite presenting a few episodes of weariness and sadness in u...