Assess Progress for Clients Receiving Psychotherapy.
PRAC 6640: Psychotherapy with Individuals Assess progress for clients receiving psychotherapy Differentiate progress notes from privileged notes Analyze preceptor’s use of privileged notes Reflect on the client you selected for the Week 3 Practicum Assignment.Assess Progress for Clients Receiving Psychotherapy. Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format. Part 1: SOAP 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.) •Assess Progress for Clients Receiving Psychotherapy. 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 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. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development, 80(3), 286. https://doi-org.ezp.waldenulibrary.org/10.1002/j.1556-6678.2002.tb00193.x Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.Assess Progress for Clients Receiving Psychotherapy.
Assess Progress for Clients Receiving Psychotherapy
Part 1: SOAP Progress Note
“We seem to be having a better relationship with the children. However, it still feels punishment helps instill discipline”
The family continues to participate in structural family therapy. The father reports that as parents they have gained good parenting skills such as active listening to the children and improved communication with the children. They have also started using punishments such as withdrawing privileges and rewarding good behaviors, rather than physical punishments for the children. The father reports that this has made the children more obedient without the need to use verbal or physical punishment.Assess Progress for Clients Receiving Psychotherapy.
Allergies: “Needs to be added to.”
Medications: “Needs to be added to.”
The two clients and their children are oriented to time, place, person, and event. They have all dressed appropriately and seem to be in good health. They all appear calm and they seem to be interacting well as a family.Assess Progress for Clients Receiving Psychotherapy.
Vitals: “Needs to be added to.”
MENTAL STATUS EXAMINATION: The speech of the parents and the two sons is coherent and normal and they are all oriented to time, place, event, and person. PTSD was noted for the parents since their childhood as they underwent severe punishment. Their thought process appears normal and normal insight. Their mood and affect are appropriate and their insight and attitude appear to be normal. The speech is also okay.Assess Progress for Clients Receiving Psychotherapy.
Diagnostic Impression: Inadequate parenting skills
The clients were cooperative during the treatment sessions. However, I noticed that the father was generally a “rough” and abrasive person. The mother seems to suffer from anger issues. They are not very willing to take part in the therapy but the fear of their children being taken away makes them cooperate. They seem to love their children; despite the excessive punishment they give their children. If the clients continue attending therapy sessions, they will gain the appropriate parenting skills as they seem ready to learn.Assess Progress for Clients Receiving Psychotherapy.
The main items found in privileged notes include the individual analysis of the contents discussed during the therapy session (Yu et al., 2017). Therefore, the content of the privileged notes includes my personal thoughts, feelings, and judgment about the sessions and the condition of the clients. According to Brattland et al (2018),some aspects that should not be included in the privileged notes include the diagnosis or the treatment plan. My preceptor utilizes privileged notes for the clients and she includes items such as her personal analysis and intuitions about the progress of the clients. The preceptor also adds private conversations with the client to the privileged notes because such information cannot be included in the soap progress note.Assess Progress for Clients Receiving Psychotherapy.
Brattland H, Juni H, Olav B, Binder P & Iversen V. (2018). Learning from clients: A qualitative investigation of psychotherapists’ reactions to negative verbal feedback. Psychotherapy Research. 28(4), 545-559.Assess Progress for Clients Receiving Psychotherapy.
Wallin, M. I., Dahlin, M., Nevonen, L., &Bäärnhielm, S. (2020). Patients’ and clinicians’ experiences of the DSM-5 Cultural Formulation Interview: A mixed-method study in a Swedish outpatient setting. Transcultural Psychiatry, 1363461520938917.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Yu, M. M., Weathers, A. L., Wu, A. D., & Evans, D. A. (2017). Sharing notes with patients: A review of current practice and considerations for neurologists. Neurology. Clinical practice, 7(2), 179–185.Assess Progress for Clients Receiving Psychotherapy.