Assessing Client Family Progress
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.
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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: (My week 3 practicum assignment had to do with a 26 year old male, who is in drug and alcohol rehab who uses IV heroin, snorts oxycodone and alcohol. He uses all of his family’s money to buy drugs and alcohol. This particular client makes jokes about everything, he does not take take anything serious. He has a daughter whom he says that is sad that he can’t see. Behavioral therapy is the treatment modality used. The client needs help with self esteem issues and I feel as though he is immature and needs to grow up.)
- 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.
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.
Assessing Client Family Progress
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.
SAMPLE ANSWER
Assessing Client Family Progress
Part 1: Progress Note
| DSM-5 diagnoses
Substance abuse: Alcohol, IV heroin and oxycodone |
|
| ASAM dimension
Dimension 3: emotional behavioral and cognitive conditions |
|
| Subjective | The patient is twenty-six years of age and was involved in substance use. The diagnosis shows that he used alcohol as well as IV heroin and oxycodone.
He reports being afraid of a relapse because the withdrawal symptoms are overwhelming. He says “I have strong cravings and I should get something stronger which sill manage these cravings” However, he makes so many jokes and especially about the issue at hand. He also says “ I don’t believe in treatment” He is also sad because he misses his daughter |
| Objective | Patient has self-esteem issues and does not feel confident about the decisions that he makes. He is not able to effectively identify the triggers because he does not seem to take the treatment seriously. However, he believes that being in rehab has helped him stay away form triggers such as being around people that sue the substances.
There is improvement in withdrawal symptoms and most of them have resolved. He however still has strong cravings despite being on Acamprosate (Campral®). The patient is still sad that he is unable to see his daughter because she is away. |
| Assessment | There has been minimal progress towards the agreed-upon goal, which was to help him take life seriously and embrace life fully. Clinical symptoms of self-esteem issues are improving and the patient is becoming more confident in the process although there are several cases where there is relapse and he becomes unserious. Self-esteem issued has been established to have a connection to abuse of drugs and therefore need to be properly addressed so as to help in recovery from substance and alcohol use (Alavi, 2011).
Clinical consultations have been made with Dr. Xavier through a phone call and there was an agreement that he continues with the procedure. A consultation was made with Dr. Emma, marriage/family therapists and there is a need to have his close family support him through the session. He should be on close observation and if he continues to exhibit depressive symptoms and sadness, it would be appropriate to provide further mental and physical health follow up.
|
| Plan | The diagnosis shows that he used alcohol as well as IV heroin and oxycodone. Psychotherapy is the approach that is used for treatment and the modality used is behavioral therapy.
Plan for substance use There has been minimal progress towards the agreed-upon goal, which was to help him take life seriously and embrace life fully. Client will continue with the medication that is provided. The patient is taking medication, which is important for two main reasons; to manage the withdrawal symptoms and to prevent a relapse (National Institute on Drug Abuse, 2019). This patient is currently taking Acamprosate (Campral®), to help with the treatment of the addiction. The main role of this drug is to reduce the symptoms of withdrawal such as anxiety and insomnia as well as dysphoria (Mason, 2015). The patient complies with the treatment regimen although he needs to be assessed due to lack of seriousness and the tendency to view everything as jokes. Plan for mental health Mental health assessment is required.
|
| Provider name and signature
………………………………. ………………………… |
Date ………/……/…….. |
Part 2: Privileged Note
The privileged notes include the observations made such as the fact that this patient acts immaturely and needs to grow up and start acting like an adult. It also includes hypotheses on the treatment plan and especially how to go about the next sessions with the patient. It also includes questions to ask other consultants such as the medication options and whether to increase or decrease the dosage. The privilege notes are different from the progress notes and do not include information such as the laboratory test results, or details on medication. It also does not have information regarding the diagnosis and treatment plan summaries as well as a summary of progress.
Assessing Client Family Progress
The items listed in the privilege note are not included in the client family’s progress note because the information is usually private and is not supposed to be accessed by the patient. It is required under HIPAA that the information is not disclosed to other colleagues unless with the consent of the patient. The notes are only important to me as the counselor and they are not used by any other party including the insurance. My preceptor made use of privilege notes. It included information such as the preceptor‘s observations and an outline of the information that occurred during the counseling session. The aim may have been to document the thoughts and feelings that they have and also come up with a hypothesis that will be useful in exploring the next sessions with the patient.
References
Alavi H. R. (2011). The Role of Self-esteem in Tendency towards Drugs, Theft and Prostitution.
Addiction & health, 3(3-4), 119–124
Mason, B. J. (2015). Acamprosate, alcoholism, and abstinence. The Journal of clinical
psychiatry, 76(2), 224-225.
National Institute on Drug Abuse, (2019). Treatment Approaches for Drug Addiction. Retrieved
from: https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
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