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.

Part 1: Progress Note

Using the client from your Week 3 Assignment, 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 from the Week 3 Practicum Assignment.

  • 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.7Practicum – Assessing ClientsPsychotherapy Individual: Prac 6640

    6/21/2020

    Practicum – Assessing Clients

    Part 1: Comprehensive Client Family Assessment

    Demographic Information

    Name: Camila R

    DOB: 2/20/1988

    Age: 32

    Gender: Female

    Race: Hispanic American

    Facility: REH Crisis Stabilization Program

    City: Minneapolis

    State: MN

    Presenting Problem

    Substance abuse, social withdrawal, and excessive worry.

    History or Present Illness

    Camila is an immigrant from Mexico. She left the country in search for a well-paying job that could cater to her needs and those of her family. However, so far, she has only managed to get minimum-wage jobs, which are not able to sustain both her and her family. Consequently, she has entered a depressive state due to her constant worrying about the future. She uses marijuana and alcohol as coping mechanisms. Shanmugam (2017) notes that this is a common trend among many addicts. Her constant worrying has made her irritable and withdrawn from her friends. Camila feels that she needs to get over her mental problems if she is to keep on working hard for the sake of her family.

    Past Psychiatric History

    Camila has noted that most of her days are spent worrying about money and where she can find a good job that will meet all her needs adequately. Consequently, she has had to depend on drugs and alcohol for solace. Whenever she is high, she forgets about her issues. However, her substance abuse is getting out of hand because it is affecting her performance at work. She has been irritable, angry, unable to get along with others, had mood swings, and has even had thoughts of suicide. Camila worries that if this trend continues, she will lost the only job she has with no guarantees of getting another one soon.

    Medical History

    Camila has been taking prescription antidepressant medication. She has been consuming 20 mg of Prozac per day. The medication has made her feel better but has not eradicated her problem.

    Substance Use History

    Camila has abused alcohol for approximately eight years. She has also taken excessive amounts of marijuana for the past year. She desires to be treated for both her substance abuse and her mental problems.

    Developmental History

    There is no available history since Camila is an immigrant from Mexico and has only stayed in the country for one year.

    Family Psychiatric History

    There are no records of Camila’s family psychiatric history.

    Psychosocial History

    Camila’s problems have made her withdrawn from her friends and family. She rarely interacts with close friends and prefers meeting with strangers whose she feels will not judge her apparent ‘failure in life,’ as she puts it.

    History of Abuse/Trauma

    Camila was raped on her way home from work this year. This episode triggered her excessive use of marijuana to cope with the feelings of shame. Acierno, Resnick, Flood, and Holmes (2003) assert that many women turn to drugs after being raped to handle the emotional turmoil. She did not report this case to the local authorities or to her family, preferring to suffer alone.

    Review of Systems

    GeneralCamila appears to be oriented to her surroundings. She answers queries succinctly and appears to be of sound mind. However, she only weighs 100 lbs. This is quite low for a woman whose height is 5’10. She attributes this to lack of appetite.

    Skin, Hair, NailsAll these factors appear normal.

    HEENT – Camila states that she does not have a headache. However, due to her poor eating habits, she regularly experiences dizziness and has even had syncope in the past. Her vision and hearing are relatively good.

    Cardiovascular : Camila states she has never had any chest pains or heart issues. Her BP is 120/80. She has a regular heartbeat of 90 beats per minute. She has a regular heart rate of 90 beats per minute.

    Pulmonary : Despite being a smoker, Camila says she has no breathing or respiratory issues. She has a 98 percent oxygen saturation.

    Gastrointestinal : Camila’s bowel movements are regular.

    Genitourinary : Camila’s urinary pattern is regular

    Neurologic : Camila states that she has never been diagnosed with a neurological problem.

    Musculoskeletal – Camila states that she has never been diagnosed with a musculoskeletal problem. However, she has slight back and knee pains.

    Hematology : Camila states that she has never been diagnosed with any blood disorders or malignances.

    Endocrine : Camila’s endocrine functions are normal.

    Physical Assessment

    Camila is alert and appears her age. However, she is underweight (100 lbs) for a height of 5’10. As aforementioned, her vitals are normal, that is cardiovascular, pulmonary, neurological, and gastrointestinal, among others.

    Mental Status Exam

    Camila was very coherent during the exam. She tried to maintain constant eye contact and effectively answered all questions concisely. However, she was moody and appeared distant at times. She was fidgeting all the time and noted it was due to her withdrawal from alcohol. Nonetheless, she was not delusional or paranoid. She was aware of her mental issues, which she stated had adversely affected her relationship with her family and friends. Camila took the Patient Health Questionnaire-9 (PHQ-9) and got a score of 25, which depicts severe depression.

    Differential Diagnosis

    Camila was diagnosed with severe substance abuse and depression.

    Case Formulation

    Camila’s mental issues have likely arisen from her inability to cater to the needs of her family. Everyone seems to look up to her and she is overwhelmed with the responsibility bestowed upon her. Additionally, the rape incident made the situation worse.

    Treatment Plan

    Goal 1

    Camila will successfully undergo treatment for drug and alcohol abuse.

    Objective

    Camila will take all the necessary steps to be admitted into Park Avenue Women’s Center.

    Intervention

    Camila will be subjected to motivational interviewing. This model takes the form of counselling where the patient is encouraged and pushed to adopt positive behavioral changes. The changes are expected to lower Camila’s addictive habits.

    Goal 2

    Camila will effectively reduce and manage her social withdrawal, excessive worry, and anxiety

    Objective

    Camila will adopt effective coping skills through therapy techniques and use of antidepressant medication.

    Intervention

    Camila will be subjected to cognitive therapy and antidepressants.

    Part 2: Family Genogram

    Camila’s child is 10 years old

    Camila is separated from her daughter’s father

    Camila’s extended family lives in Mexico

    References

    Acierno, R., Resnick, H. S., Flood, A., & Holmes, M. (2003). An acute post-rape intervention to prevent substance use and abuse. Addictive Behaviors28(9), 1701-1715.

    Shanmugam, P. K. (2017). Alcoholism & Drug Dependence. Journal of Alcoholism & Drug Dependence5(4).

    Running head: Assignment 2: Practicum 1

    Assignment 2: Practicum 8

    Assignment 2: Practicum – Assessing Client Progress

    NURS 6640

    There are differences regarding what is documented in the patient’s record and the scribed personal observations of the psychotherapist. Indeed, this paper will explore the soap note by utilizing information from week three. Also, there will be a week-three privilege note constructed, along with a discussion of the differences of the privilege note and the notes made in the patient’s medical record.

    Week Three SOAP Note

    12/12/19 14:00 (S) “I feel depressed, stressed anxious, and unbalanced.” Also, patient stated, “I get shaky and sweaty.” Recent History: The patient reports problems in his marriage, intimate relationships, and with others including paranoia, reduced sleep and appetite, worried about finances, excessive talking. Personal History: The patient had mental treatment at Hospital USA decade ago. Previous diagnoses include bipolar disorder, schizophrenia disorder, and history of substance abuse. The patient was raised by both parents, including one older brother, and a younger sister. The patient stated that his family moved around a lot, and he “never was stable in school. Also, patient was on psychiatric medication as a child, and witnessed violence between his parents, and violence on the streets where he grew up; additionally, the client reports witnessing a friend overdose on drugs. The patient stopped attending school around age 13 after he was “put out by school security.” The patient left home at age 13 due to his mother not providing – “she was a heroin addict.” (O) Flight of ideas with rapid, loud, paranoid, persecutory, trouble concentrating pressured speech, and frequently labile mood (A) Bipolar 1 disorder, depressed, severe [F31.4, DSM code] and Generalized Anxiety Disorder [F41.1, DSM code]. Clinical impressions: Rule out Bipolar I given the hypomanic symptoms. (P) Rescheduled for 01/12/20 @ 2 p.m.; Prognosis fair, due to the patient’s current hypomanic state.

    Patient to see Dr. N after therapy for psychotropic medication session to review the current medication regimen of Prozac and Trazadone. Referred to NAMI for family therapy. Next session: Continue cognitive behavioral therapy sessions and assign reading homework: Cognitive-Behavioral Therapy Program–Workbook by Grant, Donahue, and Odlaug) (Cameron & Turtle-Song, 2002).

    Part Two: The Privilege Note

    12/12/19 14:00: During the meeting with the patient, I noticed that the patient was more manic than usual, which leads me to believe he may not be completely compliant with his medication regimen. Moreover, the patient’s marital problems may also be exacerbating his bipolar condition and increasing his insomnolence; thus, there may need it will be essential to review the effectiveness of the current psychopharmacology in the next session. In summary, I believe that the client has plateaued his motivation toward his therapeutic goals; nevertheless, I will defer confronting this concern until after reviewing the progress with the patient at the end of the next meeting (The Differences Between Psychotherapy Notes and Progress Notes, 2018).

    Privilege Note Versus Progress Note

    Privilege notes are the personal notes of the psychotherapist’s observations and impressions of the patient. The privilege note will include items such as the psychotherapist’s hypothesis, observations, thoughts, and feelings regarding the patient’s unique condition. The privilege notes serve as an essential tool that the clinician refers to when determining an effective treatment plan (The Differences Between Psychotherapy Notes and Progress Notes, 2018).

    .

    Also, privilege notes are kept separate from medical records and billing information, and providers must have the patient’s authorization before sharing the notes; paradoxically, the patient does not have a right to access the privilege notes (The Differences Between Psychotherapy Notes and Progress Notes, 2018).

    Preceptor’s Privilege Notes

    The preceptor utilizes privilege notes in her everyday practice. Indeed, the preceptor will scribe observations and opinions immediately after the meeting. The preceptor takes no more than a few minutes to make the privilege note, and she will refer to them in the next meeting (Cameron & Turtle-Song, 2002).

    Conclusion

    The clinician must understand the nuances of patient documentation. Indeed, documentation in the patient’s medical record contains data pertinent to the direct care of the patient. In contrast, the privilege note serves the clinician as a personal record of impressions and observations. Ultimately, both types of notations serve to enhance the patient’s overall standard of care.

    References

    Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x

    Psychotherapy Notes and HIPAA. (n.d.). Retrieved January 12, 2020, from https://psychcentral.com/lib/psychotherapy-notes-and-hipaa/

    The Differences Between Psychotherapy Notes and Progress Notes. (2018, June 8). ICA Notes. https://www.icanotes.com/2018/06/08/the-differences-between-psychotherapy-notes-and-progress-notes/

    References

    Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x