Nursing
Title: GROUP THERAPY
Number of sources: 4
Paper instructions:
Part 1: Progress Note
Based on the order #11591
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.
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.
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Progress Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Progress Note
Date of Exam: 11/10/2020
Time of Exam: 10:00 AM
Patient Name: ‘Bereta Kyle’
Treatment Modality and Efficacy of Approach
The treatment modalities applied for the client in the case study include psychological Assessments, psychotherapy, and medication treatment. The medication regimen was fluoxetine 20mg daily. Individual psychotherapy was another important approach. The additional modalities include referral to family therapy and psychiatrist. The treatment modalities are effective in generating positive outcomes in the symptoms. For instance, the medication will help the patient recover from depression.
Progress and/or lack of progress toward the mutually agreed-upon client goals
Short-term goals: The client should report side effects of fluoxetine 20mg daily by 13/10/2020. She did not report any side effects of the disease.
Long-term goals: The client should improve on various symptoms, including lack of interest, suicidal ideation, and sadness. Improvement of the symptoms will lead to better performance at work and relationships with other people.
The client is making progress to recovery, such as interacting with people and gaining interest in daily activities.
Modification(s) of the treatment plan
There is no modification of the treatment plan at the moment.
Clinical impressions
Clients shares clinical impressions. The impressions show that the client is improving significantly over the last few days. For instance, the client continues to attend church services and support group meetings. The mood has improved at the workplace.
Relevant psychosocial information
The client will work on improving aspects such as communication, socializing, and attending weekly activities. For instance, the client should attend church services to improve interaction with other people.
Safety Issues and Clinical Emergencies
The client has not experienced any clinical emergency since the beginning of treatment. She only shows moderate signs of lack of interest, sadness, and loss of appetite. The emergencies are thus not captured in the treatment plan.
Medications and Treatment compliance
The client should take fluoxetine 20mg daily for the next two weeks. The medication regimen was started on 12/10/2020. A monthly medical review is necessary to gauge if the patient should continue taking the medication, or the medication should be changed or adjusted. The client has been consistent in taking medication since initiation.
Clinical consultations and Collaboration
Consultation and collaboration with a family therapist are completed. Further consultation with a psychiatrist is required bi-weekly in the office conference room. The family therapist will provide consultation monthly via the phone. The purpose of consulting a family therapist and psychiatrist is to address the multiple issues the client is going through (Juhos & Mészáros, 2019). For instance, the family therapist will address the client’s issue, saying the mother has a history of postpartum depression.
The therapist’s recommendations
The client is making significant progress with the current treatment plan. For instance, the client is responding positively to fluoxetine 20mg daily. She should continue with the medication for another two weeks. The current ongoing individual therapy should continue, plus attending the support group meetings. The purpose is to improve the ability to socialize, express emotions, and develop positive behavior (Juhos & Mészáros, 2019). The client is comfortable with the recommendations.
Referrals made/reasons for making referrals
The client was referred to a mental illness group with other people suffering from a major depressive disorder. The purpose is to help the patient understand the struggles other people are going through and how they overcome the challenges (Juhos & Mészáros, 2019). It will provide first-hand information about symptoms and treatments.
Termination/issues
No termination issues were noted with the client, insurance, or co-payers during the psychotherapy session’s tenure.
Issues related to consent and/or informed consent
No issues related to informed consent.
Information reflecting the therapist’s exercise of clinical judgment
The consent to clinical judgment was obtained. Differential diagnosis of major depressive disorder, seasonal depression, and substance-induced depressive disorder were made. A treatment plan was designed, including a comprehensive assessment. The purpose is to achieve mental stability and overcome the major depressive disorder.
Part 2: Privilege Note
Bereta Kyle (not her real name) experiences major depressive disorder. She shares her experience of losing interest in daily activities, suicidal ideation, and sadness. She states that the experiences started after her boyfriend decided to break away from her and abused her in public. Bereta is thus afraid of interacting with people. She feels worried and lacks interest in interacting with other people. The client feels worthless and feels suicidal. She states that her friends are getting married while she has no stable relationship. The client thus requires support and compliance with the treatment plan to realize the expected outcomes.
The privileged note information could not be included in the client family’s progress note since they contain confidential information (Pamfile et al., 2020). Confidentiality is essential during treatment since it helps clients develop trust in the psychotherapeutic relationship (American Psychiatric Association, 2019). When clients learn their private information will not be shared with the public, they are free to share confidential details that can help a therapist during treatment.
The client is open and cooperative during treatment. The treatment plan should comprise individual psychotherapy, building trust, and rapport (Mueller et al., 2018). In the practicum experience, the preceptor uses privilege notes to keep patient confidentiality and privacy during treatment.
References
American Psychiatric Association. (2019). American psychiatric association. Retrieved from https://www.psychiatry.org/psychiatrists
Juhos, C., & Mészáros, J. (2019). Psychoanalytic psychotherapy and its supervision via videoconference: experience, questions and dilemmas. The American Journal of Psychoanalysis, 79(4), 555-576.
Mueller, C. B., Kirkpatrick, L. C., & Richter, L. (2018). Psychotherapist-Patient Privilege. C. Mueller, L. Kirkpatrick, & L. Richter, Evidence, 5.
Pamfile, D., Soldati, L., Brovelli, S., Pécoud, P., Ducommun, I., Micali, N., … & Typaldou, S. (2020). Role of the psychiatrist-psychotherapist in the assessment and treatment of gender dysphoria. Peer-reviewed Journal, 16(709), 1877-1880.
