Assessing Client Progress Assignment

Assignment 2: Practicum – Assessing Client Progress
Learning Objectives
Students will:
Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
To prepare:
Reflect on the client you selected for the Week 3 Practicum Assignment.
Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format Assessing Client Progress Assignment.
The Assignment
Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
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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 Assessing Client Progress Assignment.

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.

Note: Please refer to Order # 202847 for the client information. References should be no more than 5 years old.
Progress Note

Subjective Data

This is the progress note of J. H who is a male Latino aged 11 years that presented with symptoms of inattentiveness, excessive talking, fidgeting, excessive loneliness and social withdrawal that led to the diagnosis of Attention Deficit Hyperactive Disorder(ADHD) that had also been diagnosed previously. The patient was immediately started on pharmacological therapy where Ritalin LA 60mg was prescribed. The patient was also started on behavioral training for the purposes of enabling him to develop closer relationships, for the acquisition of social skills, reduction of behaviors that are undesirable and antisocial and for the acquisition of skills for problem-solving.

During today’s follow up, the client reported that behavioral training has been essential since he can efficiently and effectively manage her behaviors. He also reports that he can comfortably socialize with friends and family members without feeling the urge to be alone. He has been able to perform activities of daily life with minimal assistance from his mother. He can try and concentrate on a specific activity for some longer period of time as compared to before. However, the client also feels that behavioral training has not been significantly effective basing on the fact that he cannot concentrate on a particular activity for some considerable period of time. Currently, he is sure that, if he continues with behavior training, it will be possible for him to effectively manage his behavior by paying attention to specific activities for longer and freely interacting with schoolmates, friends, and family Assessing Client Progress Assignment.

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Objective Data

Clinically, JH was composed, calm and paid attention during the first 30 minutes. He communicated in sentences that were well structured and he felt satisfied with the information that he provided. JH was also happy with the sessions of behavioral training significantly promoted his ability to put more effort on desired behaviors and to do away with those that are no longer pleasant. Besides, his parents were able to learn how to reward specific behaviors that are desirable for promoting them and to punish or ignore those that are undesirable to decrease them (Singh, et al., 2015). Through collaboration with the parents, the client was encouraged to sustain actions that were positive and to do away with those that are undesirable by: establishing clear schedules and routines, allowing the occurrence of natural consequences and providing chances for rectification, establishing expectations of behavior and emphasizing on the need for supportive environments for quality health outcomes (Wilens & Spencer, 2014). So far, the patient was certain that nothing could possibly derail or hinder him from attending sessions of behavior training. However, the client was easily distracted by the surrounding environment such that, he was not able to concentrate during the last 15 minutes of the session. However, he had attended all sessions for behavior training.

Assessment

Although the patient still displays some symptoms of Attention Deficit Hyperactive Disorder (ADHD), his overall status reveals some significant improvement. This is an indication that, the current pharmacological therapy and psychotherapy are not only effective but also efficient as anticipated. Currently, the patient is still not able to pay attention to particular activities for quite a long period of time as he is easily distracted by the surrounding environment and any other activities that may be going on. The decision to include his caregivers and teacher as part of the sessions in behavioral training was commendable as they all played an integral role in ensuring that the patient established and meet specific behavioral expectations (Rodríguez, et al., 2016).

So far, the patient has adhered to medications and was on Ritalin LA, 60mg and drugs for asthma which are Advair inhaler 100/501 puff INH BID, Proventil inhaler 2 puffs INH pm. Owing to the fact that the patient displayed and admitted to symptoms of lacking concentration, it would be necessary to continue with both pharmacologic and psychotherapy.

Plan

The patient’s presentation during this follow-up presents the need to continue with behavioral training and pharmacological therapy. During the follow-up session, it was notable that the patient was easily distracted with the surrounding. As a result, in the behavior training sessions, more emphasis will be laid on the development of written contracts for particular changes in behavior with the use of specific techniques that shape behavior Assessing Client Progress Assignment.

Privileged Note

The patient in this scenario typically presents as one with Attention Deficit Hyperactive Disorder in reference to the symptoms of fidgeting, lack of paying attention, social withdrawal and loneliness. Patients with ADHD on pharmacological treatment and behavioral training show improved health outcomes as it is in this case. However, the non-improvement of symptoms should be an indicator of treatment failure. My preceptor prefers using progress notes to privileged notes. This is so because the former is detailed, comprehensive, formal and more scientific in comparison to the privileged note. As noted by Shier, et al., (2015), in writing privileged notes, a mental health nurse is expected to document immediate changes after observation with no specific writing format.

References

Rodríguez, C., González-Castro, P., Cueli, M., Areces, D., & González-Pienda, J. A. (2016).

Attention Deficit/Hyperactivity Disorder (ADHD) Diagnosis: An Activation-Executive Model. Frontiers in Psychology, 7, 1406.

Singh, A., Yeh, C. J., Verma, N., & Das, A. K. (2015). Overview of Attention Deficit Hyperactivity Disorder in Young Children. Health Psychology Research, 3(2), 2115.

Shier, A., Reichenbacher, T., Ghuman, H. & Ghuman, J. (2015). Pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: clinical strategies. Journal of Central Nervous System Disease, 5, 1-17.

Wilens, T. E., & Spencer, T. J. (2014). Understanding Attention-Deficit/Hyperactivity Disorder From Childhood to Adulthood. Postgraduate Medicine, 122(5), 97–109 Assessing Client Progress Assignment .

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