Assessing Client Family Progress Essay

Posted: November 1st, 2022

Assessing Client Family Progress Essay

Assignment 2: Practicum – Assessing Client Family Progress Learning Objectives Students will: 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. The 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. Assessing Client Family Progress Essay.  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. Assessing Client Family Progress Essay

Assignment 2: Practicum – Assessing Client Family Progress

Part I: Progress Note

This client family progress note assesses Mr J.D, a 39-year-old Muslimwho had been brought by his sister at the therapy session. Mr J.D has changed his behavioursafter being discharged from the military.Additionally, Mr J.D has increased his drug use and alcohol consumption. The client reports that he started abusing drugs and alcohol to cope with his stressful condition which is t adapt to life at home with no job after discharge with significant financial responsibilities. The client also mentions that he has been feeling worthless and sad with lack of interest in doing sporting activities that he previously engaged in with his close allies. Furthermore, Mr J.D feels dejected, empty, hopeless and melancholicmaking him spend most of his precious time either using drugs or drinking. Besides, Mr J.D had shown lack of interest in activities which he previously considered his hobbies.The client also suffers from insomnia because he lacks motivation and he feels that he is not making any life progress. This made her sister become very concerned and brought by his sister at the therapy session. Assessing Client Family Progress Essay

Subjective

Mr J.Dreported that considering he is in a good position to manage his increased his drug use and alcohol consumption, the interpersonal therapy has been successful. The client claims that through the coping skills offered;he could relate well with other people by engaging in various activities. However, he claims that the family-focused therapy is not essential considering hismarital status. Mr J.D presently tends to think that the therapy session will help him and improve his condition and he is more than ready to follow all the recommendations provided by the therapist.

Objective

Throughout the therapy session, MrJ.D seemed to be calm. Additionally, the client talked positively regarding his condition and made well-structured sound remarks. He also seemed happy and delighted concerning the therapy session. Furthermore, the clientwas prepared to continue attending the classes. He reports that he loves attending the classes and nothing else could make him withdraw.Mr J.D is ready to ensure that his condition improves and he attended all the therapy sessions. Assessing Client Family Progress Essay

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Assessment

In spite of little sadness episodes with lack of interest in doing sporting activities, the client’s status have improved greatly according to the psychological status examinations. This proves that the present treatment modality is working as anticipated. Mr J.D current clinical implication consists of altered mood. This is demonstrated by episodes of sadness. However, the family therapy logistics are being effective considering his marital status and his sister is often available during the family-therapy sessions.

Plan

With the persistent problem in the family therapy, cognitive behavioural therapy and good collaboration and relationship between the client and therapist to change family therapy’s schedule to ensure that the sister always participates (Rice et al. 2018). On the other hand, the therapist is supposed to prescribe antipsychotic medications (Webb, Hayes, Grasso, Laurenceau & Deblinger, 2014). These medications will help the client to manage his condition. The client must also continue with interpersonal therapy through completing all the sessions. Assessing Client Family Progress Essay

Privileged note

Mr J.Dis a goodexample of an individual who is frustrated and unsatisfied given that he still presents episodes of sadness and this could make him continues abusing drugs and using alcohol. Moreover, he claimed that he is not able to adapt tosignificant financial responsibilities. The client claims that when he encountered episodes of sadness and worthless, he would still think of abusing drugs and alcohol. Clients who plan to abuse drugs and alcohol due to stressful situations can be helped through further assessment and thorough treatment (Jelalian et al. 2016).In case the appropriate treatment is not used, then such client might become suicidal. In case the client would have been married, probably, the situation of the client would be better. Assessing Client Family Progress Essay

We cannot exhibit the information provided in the privileged note in the progress note because it is confidential. Furthermore, such information should not be provided to other people or other parties because it should only be usedby the therapist and theclient (HHS.gov, 2017). This information are confidential and private that should not be shared with other parties. When dealing with psychological disorders which lead to drug abuse and alcohol consumption, my preceptor utilizes privileged notes. He mostly uses the privileged note to preserve information that is related to the encounters of the clients who abuse drugs and alcohol that came across before, plus the best strategies for treating any related issues. Assessing Client Family Progress Essay

References

Jelalian, E., Jandasek, B., Wolff, J. C., Seaboyer, L. M., Jones, R. N., &Spirito, A. (2016).Cognitive-behavioral therapy plus healthy lifestyle enhancement for depressed, overweight/obese adolescents: results of a pilot trial. Journal of Clinical Child & Adolescent Psychology, 1-10.

Rice, S., Halperin, S., Blaikie, S., Monson, K., Stefaniak, R., Phelan, M., & Davey, C. (2018).Integrating family work into the treatment of young people with severe and complex depression: a developmentally focused model. Early intervention in psychiatry, 12(2), 258-266.

Webb, C., Hayes, A. M., Grasso, D., Laurenceau, J. P., & Deblinger, E. (2014). Trauma-focused cognitive behavioral therapy for youth: Effectiveness in a community setting. Psychological trauma: theory, research, practice, and policy, 6(5), 555.

HHS.gov. (2017). Information Related to Mental and Behavioral Health. [online] Available at: https://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/index.html [Accessed 11 Oct. 2018]. Assessing Client Family Progress Essay