Assessing Client-Family Progress Paper

In Mental Health, the use of privileged notes and progress notes is common and they both safeguarded by the HIPAA to ensure confidentiality and privacy on the documentation and analysis of the information collected during a therapy session. While progress notes are part of a patient’s medical record and they have a legal right to inspect them, it is mandatory that they are readable. However, privileged notes are always separate from the records of a client and patients do not own any rights to view them unless compelled by legal action for their release. This paper details a comprehensive progress note and privileged note of a 13 y/o girl who diagnosed with schizophrenia and admitted to a juvenile inpatient psychiatry unit in the past two weeks. The patient was placed under CBT and other pharmacological drugs for anxiety and depression. Assessing Client-Family Progress Paper

Part 1: Progress Note

Subjective Data

In week 3, I assessed AR who was a 13y/o female on a 1013 hold and had presented with behavioral problems, suicide idealization, agitation, delusions, hallucinations, a past medical history of suicide, depression and a suicide attempt. Following the diagnosis of Schizophrenia, the patient was started on CBT alongside medications. During today’s follow-up, the client reported that the CBT approach has been helpful since she can effectively manage her anger and behavior. She is able to interact with close family members openly, especially her mum and siblings without transferring feelings of anger, resentment or hate. She has been able to resume her normal daily routine where she performs activities of daily life without assistance and can spend time drawing or painting in the inpatient psychiatric unit as she continues with therapy.

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However, the patient adds that, she feels individual CBT is not very effective considering that she keeps remembering the conflicts she had with her mother who just come to visit on different schedules. Currently, she is certain that as she continues with the therapy, she will be able to overcome anxiety and depression to positively influence her thoughts, feelings and behavior (Crane-Okada, 2012).

Objective Data

Clinically, the client was calm and composed in the entire session of therapy. She talked in well-structured sentences and was positive and confident in what she said and how she felt. The patient was also happy about the sessions of therapy as she noted that they contributed to her piece of mind, the ability to identify negative thoughts, behavior and feelings through self-monitoring and to view issues from a different perspective using behavioral experiments (Lerner, McLeod & Mikami, 2013). To this extent, the patient progressively noted that nothing would result to her withdrawal from the therapy sessions and planned. The client was easily angered and agitated with thoughts or opinions that conflicted with hers and thoughts of committing suicide escalated at this time. Apparently, the patient had attended all the sessions of therapy but missed three sessions with her mother.

Assessment

Despite the fact that the patient has some concern for her mother’s and grandmother’s in-attendance, there is marked improvement in her overall status which is a clear indication that, the current regimen for treatment is highly effective as expected. Currently, the client has some episodes of depressed mood which is revealed by feelings of wariness and concern and some episodes of sadness. She also feels some little agitation when her mother turns up late for sessions or when her grandmother fails to attend. It is worth noting that, including her mother and grandmother in the therapy has proven to be fruitful given that they were all affected directly or indirectly by the patients’ health status. The patient has been compliant to treatment and was on Celexa 10 mg PO, Prozac 20 mg PO for mood and Ativan 0.5 mg PO for anxiety. Since the patient still reported symptoms of changes in mood, agitation and some irritability, it was necessary to stop the medication for proper health outcomes. Prozac has been noted to have a high potential in increasing thoughts of committing suicide and hurting oneself(Crane-Okada, 2012).s Therefore, consultations were done with a pharmacist and the prescribing physician on whether to stop Prozac 20mg PO daily or whether to slowly taper off the dosage. Assessing Client-Family Progress Paper

Plan

There is the need to modify the schedule for the therapy sessions based on the schedule of the patient, her mother and grandmother which will guarantee full and active participation. To make sure that the symptoms of agitation, irritability and on-and-off depressed moods are completely eliminated, the medication of Prozac 20mg PO daily will be stopped immediately. However, she will continue with Ativan 0.5 mg PO and Celexa 10 mg PO. During the follow-up, it was noted that the patient had developed so much concern to hold sessions with family members especially those she felt that she had wronged. Therefore, the patient, her mother, and grandmother will be referred to a family therapist with whom they will collaborate in a therapeutic process to: adequately address each person’s needs, resolve conflicts that may exist and to form stronger inter-personal relations (Crane-Okada, 2012).

Part 2: Privileged Note for A Suicidal Patient

Basing on the practicum assignment for week 3 and the patient’s progress, this patient is a perfect example of an individual who easily gets angered since she still presents with episodes of irritability, agitation and changes in mood status. Besides, the client admitted to having suicidal thoughts occasionally, more so when her mother and grandmother would fail to or turn up late to see her. In such occasions, she would also experience feelings of wariness and episodes of sadness. Patients who are under psychotherapy medications and CBT and persistently present with complaints of suicidal ideation need further assessment and treatment. It is also important that the patient’s medications are reviewed to ensure that the current symptoms are not as a result of the side effects of specific drugs (Yalom, I. D., & Leszcz, 2005). Failure to do so, there are high chances that the patient may end up committing suicide. Immediate action is needed to ensure that these thoughts and feelings are completely eliminated. Perhaps, if the patient’s mother and grandmother would be visiting more often and on time, the client’s situation would be much better. Alternatively, they would all set alternative days with flexible schedules to prevent similar incidences. Assessing Client-Family Progress Paper

Basically, a privileged note in psychotherapy includes the changes and observations that are noted momentarily which have no standards, rules or form of writing. While the privileged note may include the physical observations made and the clients’ moods and responses, the progress note for the client is more formal (Nicholson, 2002). My preceptor rarely uses privileged notes. Instead, he prefers to use the progress note. This can be attributed to the fact that the progress note goes deep into details after a session with the client, allowing a mental health therapist to discuss on the observations made with terms that are more medical and to link with the daily or monthly progress of a client (U.S. Department of Health & Human Services, n.d.). As a result, the language used and content in a progress note is more formal, scientific and comprehensive as compared to the privileged note that only captures quick observations.

References

American Counseling Association (Producer). (2015). Leading counseling groups with adults: A

demonstration of the art of engagement. [Video file]. Alexandria, VA: Author.

Crane-Okada, R. (2012). The concept of presence in group psychotherapy: An operational

definition. Perspectives in Psychiatric Care, 48(3), 156–164.

Lerner, M. D., McLeod, B. D., & Mikami, A. Y. (2013). Preliminary evaluation of an

observational measure of group cohesion for group psychotherapy. Journal of Clinical Psychology, 69(3), 191–208. doi:10.1002/jclp.21933

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 March 18, 2017, from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.).

New York, NY: Basic Books. Assessing Client-Family Progress Paper

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