Treatment modality used and efficacy of the approach
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. Please include references
YOUR NAME
SUBJECT AND SECTION
PROFESSOR’S NAME
DATE OF SUBMISSION
Part 1: Progress Note
The patient selected in week 3 was A.M., a 25-year-old Caucasian female who presented with suicidal tendencies and was diagnosed with Major depressive disorder.
Treatment modality used and efficacy of the approach
In this case, the appropriate treatment modality used is Cognitive Behavioral Therapy (CBT) and engaging the patient to support groups. CBT is a psychotherapy that mainly focuses on altering and modifying the patient’s negative behavior associated with psychological distress and changing it into an adaptive behavior to maintain the patient's emotional well-being. CBT is highly effective and recommended for patients diagnosed with a major depressive disorder characterized by a constant feeling of loneliness and loss of interest and is associated with negative thoughts and behavior that could interfere with day-to-day activities (Hawley et al., 2017).
Another treatment modality used for this patient is having a support group. The support group provides a community of acceptance and belongingness for the patient wherein she can interact with other people who are also experiencing what she is going through. It is especially crucial for people with a major depressive disorder to gather hope and empowerment and support and healing from a source in which psychotherapy cannot provide. Depression worsened when an individual chose to be isolated and lonely since sustaining a perspective and maintaining an effort in dealing with the condition would be somewhat tricky. Thus, having a support group is essential for patients with a major depressive disorder to cope with their health situation through maintaining close and social relationships (Behler et al., 2017).
Progress and/or lack of progress toward the mutually agreed-upon client goals
Based on the assessment of the progress of the patient, the mutually agreed-upon goals are met. The patient showed significant results through the psychotherapy provided. The patient’s symptoms, such as stress, depression, and suicidal tendencies, were significantly improved. As shown by the PHQ 9, the patient test scores reduced from 20 to 15 in four weeks and from 15 to 9 in eight weeks of follow-up. Positive effects of the intervention were shown during the 4th week. The patient started playing the piano again as an alternative way whenever suicidal thoughts occur. She also enrolled in yoga classes as a way of managing both her positive and negative emotions. The patient further reported that her support group encouraged and empowered her, which helped her in the healing process. Additionally, the patient no longer had suicidal ideations and had returned to work four weeks ago. These results are considered the key indicators of the effectiveness of the treatment modalities used along with the patient's significant progress.
Modification(s) of the treatment plan that was made based on progress/lack of progress
Since the treatment plan (CBT and support group) conducted on the patient has shown significant results regarding her MDD symptoms, modifications were not necessary and were not done.
Clinical impressions regarding diagnosis and/or symptoms
In assessing a patient’s symptoms, the clinical impressions include the use of clinical judgment and clinical decision-making in deducing treatment modalities. Furthermore, the PHQ-9 score was used to confirm the diagnosis for MDD and exclude bipolar disorder and other mental health disorders caused by depression.
Relevant psychosocial information or changes from the original assessment
The patient is single and is working as a Physical therapist. There are no changes.
Safety issues
Considering her suicidal ideations, the patient was advised to live with her mother and her youngest sibling to help her in daily chores as well as ensuring her safety.
Clinical emergencies/actions taken
No emergency actions were taken.
Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
Citalopram (Celexa) – 20mg PO qDay
Treatment compliance/lack of compliance
The patient was compliant with all her treatment plan. Both CBT and support group sessions are attended timely.
Clinical consultations
To ensure effective treatment is provided to the patient, clinical consultations include physical visits to her primary provider and therapist and phone calls, emails, and online video-chat whenever necessary.
Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc. )
Other medical health professionals involved in the care for the patient include a nutritionist and a family therapist. The nutritionist act as a guide for the patient in managing her diet and activities for her optimal health and to address her weight-loss issue. The family therapist guides...