Patient Assessment Research Paper

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.
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):

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 Patient Assessment Research Paper.
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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.

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.
People all over the world continue to suffer from various predicaments arising from an array of factors. However, the availability of healthcare services and highly trained personnel aids in an effective treatment process. Normally, healthcare professionals are required to act in a professional manner. The aspect entails maintaining the confidentiality of patient information. Besides, clinician ought to act within the Health Insurance Portability and Accountability (HIPAA) to warrant accountability. Despite these restrictions, the American Psychiatric Association (2013) posits that clinicians are required to deduce precise diagnoses and record the exact details. Through this facet, they are able to administer the correct pharmacological and therapeutic interventions, warranting patient recovery. Nurses use the progress and privilege notes as their main communication tools to describe patient care during their hospitalization in a psychiatric ward. In the light of this aspect, it is imperative to ensure correct entry of patient data in the progress and privilege notes respectively.

Progress Note

Subjective

The patient explained of feeling better during the next visit. The potentiality of dyskinesia and hyperglycemia did not overweigh the actions of anti-psychotic medication. The 71- year old man’s overall mood was stable, displaying the efficacy of the psychotic medication. Besides, there was reduction in hostility, and the client did not have the craving of abusing any drugs.

Objective

Observations on the patient’s active range of actions revealed stabilization of his condition. He displayed no intermittent hallucinations, and he was able to recall the name of the American President quite often. However, it was noted that he exhibited poor judgments and poor concentration, especially when execution simple chores. Besides, the olds man exhibited memories of his children on the wall, albeit to a minimal extent Patient Assessment Research Paper.

Assessment

Evidently, the prognosis of the patient at this stage displays encouraging results. The patient is responding positively to the administered medication, although some symptoms are still recurrent. Additionally, he is compliant to taking medication, an aspect that would lead to timely recovery.

Procedure/Plan

Since the patient was responding positively to psychotic drugs, it is imperative to incorporate supportive care. The intervention would effectively aid in the psychological stabilization of his condition. Specifically, Butler, Begley, Parahoo and Finn (2014) state that incorporation of cognitive-behavioral therapy (CBT) would be the most appropriate approach. Particularly, CBT combines an array of theories that influence people’s behaviorism and interpretation of situations in their lives (Wheeler, 2014). Predominantly, therapists identified the unhelpful patterns in the old man’s life for instance poor social skills, which was a principal problem. The patient was structured to achieving realistic goals for instance managing stress and anxiety, and engaging in numerous social activities. The events would help stabilize his situation by creating enjoyable memories.

Privilege Note

Mr. K is a 71 years old white man, who lives in a nursing home. He suffers from mood disorder. He is religiously affiliated to the Catholic Church. After the death of his wife, he lived with a 40 years old daughter, but she later admitted him in a nursing home. He has four grandchildren, whom he communicates with through the phone. Presently, he feels agitated by the fact that he lives in a nursing home. In fact, he speculates that his children could have sold his property and forced him to stay in a nursing home. His previous medical history indicates that he suffered vascular dementia and schizophrenia. For this reason, he made frequent hospital visits since when he was 30 years old. The patient recalls events that traumatized him during childhood, but he failed to remember any form of treatment and hospitalization.

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Privilege Note versus Progress Note

A progress note contains information about the client’s clinical status. It involves that progress that the patient made during hospitalization. The progress note forms part of the patient’s record file, which follows a standard format. The progress note contains data on symptoms, assessment, diagnosis, and treatment of a patient (D’Amour, Dubois, Tchouaket, Clarke & Blais, 2014). Doctors and nurses write progress notes in order to help them analyze and compare patient’s health status. The members of the medical team use the information in the progress note to make decisions regarding treatment of the patient. The information must be readable, concise and brief for the clinical team to understand the patient’s needs. Any errors in the progress note are likely to affect patient outcomes Patient Assessment Research Paper.

Contrarily, a privilege note contains confidential information that a doctors should not disclose without patient’s consent. The information includes private information that the patient shared during an interview session. The records help the caregiver to recall important information obtained from an interaction from the patient.

The information available in the note includes the information that the patient provides during a private therapy session. During these sessions, the patient will indicate that he/she intends the information to be confidential (Kozlowski et al., 2014). However, the privilege may not include any disputes between the patient and the therapists. Moreover, the caregiver must write the privilege notes according to the provisions of the HIPAA. Nonetheless, one must discern whether the interview is important for a court case.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Butler, M. P., Begley, M., Parahoo, K., & Finn, S. (2014). Getting psychosocial interventions into mental health nursing practice: a survey of skill use and perceived benefits to service users. Journal of advanced nursing, 70(4), 866-877. https://doi.org/10.1111/jan.12248

D’Amour, D., Dubois, C. A., Tchouaket, É., Clarke, S., & Blais, R. (2014). The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review. International Journal of Nursing Studies, 51(6), 882-891. https://doi.org/10.1016/j.ijnurstu.2013.10.017

Kozlowski, L. J., Kost-Byerly, S., Colantuoni, E., Thompson, C. B., Vasquenza, K. J., Rothman, S. K., … & Monitto, C. L. (2014). Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing, 15(1), 22-35. https://doi.org/10.1016/j.pmn.2012.04.003

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 Patient Assessment Research Paper .

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