Assignment 2: Practicum–Assessing Client Progress
Assignment 2: Practicum–Assessing Client Progress
Assessing clients is among the processes of determing the progress of therapy. According to various stakeholders, the patient’s medical care, treatment plans, and other pertinent information are shared using the the progress note while priviellegd note forms an important assessment of a patient from a personal perspective. The purpose of the present is thus to formulae a progress note and privileged note regarding a patient that was assessed in the course of the present course without violating the HIPPA.
ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment 2: Practicum–Assessing Client Progress HERE
Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us
Part 1: Progress Note
Patient’s demographic information: T.C is a 73 years old African American male
[elementor-template id="165244"]Diagnoses (DSM-5): Increased psychosis with auditory hallucination (AH)
Date:
The patient was diagnosed with increased psychosis with auditory hallucination and potential harm to himself and others, and as such, a combination of medicinal and behavior modification treatment approaches will be beneficial. Other than medicinal therapy, cognitive behavioral therapy will form part of the most important aspect of patient care, helping the patient cope with his mental condition and have a different view about himself. Incorporation of CBT was effective as it helped in reducing the symptoms of psychosis, and auditory hallucination leading to positive progress in meeting the treatment goals as the patient’s compliance to medicinal therapy improved (American Psychiatric Association, 2017). Further, only a few alterations were made in the course of treating the patient. These included making certain that the patient understood the significance and aptness of taking drugs at the correct time as well as in the right manner in terms of strength, eating recommended healthy diets and doing exercises. Nevertheless, no deviation from the original assessment was noticed and neither was there any pertinent psychological information. Also, the patient has not shown any notable clinical emergencies, which demonstrates the effectiveness of the diagnosis and management of the disorder.
The patient is currently taking antipsychotic agents, which are effective, and a reconsideration of putting him on benzodiazepines to manage his symptoms of psychosis. These drugs have helped the patient manage his mood, anxiety, and insomnia among other symptoms of psychosis. However, the patient lacks family support but has been able to get assistance in taking his medication and improving his compliance at a shelter home where he currently lives. As such, engaging the patient more on cognitive behavioral therapy will help in assisting the patient gain self-worth and differentiate between acceptable and unacceptable behavioral traits (Wheeler, 2015).
Part 2: Privilege Note
Privilege note encloses patients information with regard to individual or group sessions, assessment, and available treatment options or care plan. Obtaining and the documentation of the informed consent form helps in boosting the relationship between the therapist and the patient especially when managing a psychotic disorder with auditory hallucination and suicidal thoughts. Here, private sessions between the counselor, and the patient, or group or family counseling sessions are separated from the patient’s primary medical records, as this information is confidential and only required by the therapist to help them organize and prepare themselves appropriately in developing the patient’s treatment plan (Wheeler, 2015). The privilege notes are sometimes composed of psychotherapy hypothesis, questions relating to the therapy session, and general observation of the whole process.
All the information in the privilege note is usually confidential and should not be documented together with the patient’s medical records as they are only to be used by the therapist as an added tool in formulating the patient’s treatment plan (Hayward, 2018). During my psychiatry clinical rotations, my preceptor utilized the privilege notes in understanding the patient progress with therapy and even asked him how his last session was, and what he would want changed to help in the management of his condition.
References
American Psychiatric Association., & American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.
Hayward, M. (May 01, 2018). Evidence-based psychological approaches for auditory hallucinations: Commentary On… Auditory Hallucinations in Schizophrenia. Bjpsych Advances, 24(3), 174-177.
Wheeler, K. (2015). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer Publishing Company.
[elementor-template id="165244"]