Assignment 1: Practicum – Assessing Client Family Progress
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.
Expert Answer and Explanation
Assessing Client Family Progress
Therapists are always required to develop documentation to explain the progress of their clients. The purpose of this assignment is to develop progress and privileged notes of a couple who came for therapy.
Part 1: Progress Note
Treatment Modality Used and Efficacy of Approach
The treatment modality used is cognitive-behavioral therapy. Shayan et al. (2018) did a study and found that CBT is highly effective in treating people with post-traumatic stress disorder and other stress-related conditions.
Progress Towards Goals
The therapy’s goal is to change the clients’ thoughts and attitudes towards parenting and their financial conditions. The family agreed to attend ten therapy sessions to achieve this goal. Looking at the clients’ state of mind, there is no progress.
Modification(s) of the Treatment Plan
The therapy was modified in that both the counselor and the clients agreed to increase the number of sessions to fifteen. Role-playing was also included in the therapy. Role-playing can improve their social skills and improve their problem-solving skills (Khanjani Veshki et al., 2017).
Clinical Impressions Regarding Diagnosis And/or Symptoms
Based on the clients’ medical history, they might be suffering from the acute stress disorder. The stress is caused by a lack of financial support and balancing parenting and work.
Relevant Psychosocial Information or Changes from Original Assessment
The clients have no history of psychological problems. However, there is a history of alcoholism in the family, hence putting the clients at risk of suffering alcoholism.
Safety Issues
The father works at a security company as security personnel can lead to security issues because one must protect people or property from danger.
Clinical Emergencies/Actions Taken
The family has never experienced any form of a clinical emergency.
Medications
The clients have no history of physical or mental health problems, and therefore, they are not on any kind of medications.
Treatment Compliance
The clients have not been complying fully with treatment therapy. The father noted that the timing of the sessions does not align with his working schedule. He requested that the sessions be pushed to weekends and not weekdays.
Clinical Consultations
Clinical consultation occurred with the supervisor. The supervisor was asked whether the clients can change their therapy sessions from weekdays to weekends.
Collaboration with Other Professionals
I collaborated with my supervisor, a fellow counselor, on how to handle the clients’ financial woes. Professional collaboration is a significant practice in that it helps caregivers provide patient-centered care.
Therapist’s Recommendations
The therapist recommended that the clients be involved in role-playing and that their sessions should be increased to fifteen from ten. Role-playing would help clients practice new patterns or skills of interaction (Dattilio & Collins, 2018). For instance, they would practice talking to children and engaging them in decisions affecting their lives. The clients agreed to the recommendations but noted that the fees for the sessions should be reduced a bit.
Referrals Made/Reasons for Making Referrals
There were no referrals made during the treatment session.
Termination
The five more sessions could risk termination if the clients cannot pay for them or if their insurance program refuses to pay for them.
Issues Concerning Informed Consent for Treatment
Informed consent is a significant ethical code in healthcare practice. Before a therapist makes any recommendations, the client must be asked for informed consent. The clients were asked for their informed consent before the recommendations were implemented.
Information Concerning Child Abuse
During the assessment, it was found that the clients have not a history of child abuse or dependent adult abuse.
Information reflecting the therapist’s exercise of clinical judgment
Clinical judgment is clinical reasoning that allows caregivers to arrive at a conclusion based on subjective and objective data about the patient (Dickison et al., 2019). Based on the clients’ subjective and objective data, these patients have not prior physiological or mental healthcare issues. However, the clients have financial problems because they have to care for their parents and children. They are also faced with the challenge of balancing their parenting roles and work schedule. They should be taught techniques to cope with stress.
Part 2: Privileged Note
Not all information can be included in the progress note. I can never enter pejorative or derogatory statements about the patient in the progress note but include them in the privileged note. Another piece of information that I cannot include in the progress note is complaints about other staff members, whether from the staff, doctor, supervisor, or the patient. I would include my hypothesis about the patient in the privileged note but not the progress note. Lastly, I would include my observations about the clients in the privileged note but not the progress note.
I would not include the items above in the progress note due to the following reasons. First, psychiatrists must show that they are concerned about their clients and respect them. For instance, saying that the client is lying about their health history is cruel and disrespectful, and that is how I cannot include it in the progress note. To maintain the proper relationship between staff and my client, I cannot include their complaints about each other in the progress note. Also, my observation and hypothesis about the clients can be sensitive and create a lot of emotions, and that is why the information cannot be included in the progress note. My preceptor uses privileged notes. The preceptor might include his observations, hypothesis about the patient, and questions he can ask his supervisor.
Conclusion
The progress note above has clearly shown the clients’ progress and treatment recommendations that can be implemented to improve their wellbeing.
References
Dattilio, F. M., & Collins, M. H. (2018). Cognitive-behavioral family therapy. Guilford Press.
Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the national council of state boards of nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03
Khanjani Veshki, S., Shafiabady, A., Farzad, V., & Fatehizade, M. (2017). A Comparison of the Effectiveness of Cognitive–Behavioral Couple Therapy and Acceptance and Commitment Couple Therapy in the Couple’s Conflict in the City of Isfahan. Jundishapur Journal of Health Sciences, 9(3). https://sites.kowsarpub.com/jjhs/articles/62010.html
Shayan, A., Taravati, M., Garousian, M., Babakhani, N., Faradmal, J., & Masoumi, S. Z. (2018). The effect of cognitive behavioral therapy on marital quality among women. International journal of fertility & sterility, 12(2), 99. doi: 10.22074/ijfs.2018.5257
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