Details:
Assignment 2: Practicum – 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.
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:
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.
Assessing Client Families
Part 1: Comprehensive Client Family Assessment
Demographic Information
Mr. J.M and Mrs. L. K are African American couples that have been married for 20 years. Their son, P.T is aged 14 years. J.M is aged 34 years while L.K is aged 29 years. The family lives in a middle-class suburban neighborhood outside of town. The family does not associate with any specific religion. J.M is a mechanic, although he currently does not work and L.K is a teacher in a local elementary school.
Presenting Problem
J.M presents with excessive alcohol drinking. According to history, J.M takes approximately six bottles of alcohol daily. J.M has been arrested three times in the last two weeks for engaging in a fight in the local bar. Additionally, J.M drives while drunk and has been charged with the offense in court two times in the last one week. J.M had been reporting to work after heavy drinking the previous evening. J.M has been dismissed four times by different employers for reporting to work while drunk. L.K presents with the inability to maintain concentration, failure to sleep adequately, continued sadness lack of interest in activities that she previously enjoyed and loss of appetite. L.K reports that she has lost 5 kilograms of the body in two months.
History of Presenting Problem
J.M has been taking alcohol, although moderately since at the age of 25 years. J.M has been taking approximately two bottles of alcohol at the weekends. However, for the last six months, J.M’s alcohol consumption increased drastically. One month later, J.M was diagnosed with alcohol abuse disorder and began alcohol anonymous group therapies.
At the same time, he was diagnosed with lung cancer, second stage. J.M. is currently undergoing treatment for cancer. However, according to the physician, J.M will only receive supportive therapy. J.M has been attending alcohol anonymous group sessions. L.K was well until the same time J.M was diagnosed with alcohol abuse. L.K has also been attending group therapy sessions and cognitive behavioral therapy. However, L.K’s symptoms have not improved.
Past Psychiatric History
There is no additional history of psychiatric conditions within the family
Psychosocial History
L.K’s mother was diagnosed with depression, and her father was diagnosed with schizophrenia.
Medical History
J.M is has been diagnosed with lung cancer. J.M is receiving radiotherapy and chemotherapy with pembrolizumab, 200 milligrams daily. The lung cancer was diagnosed at stage 2, but now is in stage 3.Acccoding to the physician, J.M will only be receiving conservative care.
Substance Use History
J.M presents with the problem of marijuana usage. J.M admits to having been using cocaine since at the age 20 years, until in the last one year. J.M smokes cigarette although against the advice of the physician to avoid exacerbating symptoms of the lungs cancer.
Developmental History
J.M and L.K do not report any impairment in developmental history. P.T has achieved all the milestones in time as expected. However, the teacher report that P.T’s academic performance has been dropping.
Family Psychiatric History
L.K is earning is the only source of income for the family. L.K’s earning is not sufficient for the family’s financial needs. The family does not receive any social support from outside the family.
History of Abuse and Trauma
L.K reports that she has suffered from physical and mental abused from J.M ; he has occasionally been violent towards her and their son, P.T.
Review of Systems
The patients’ respiratory, digestive, urinary, and neurological systems assessment reveals that no abnormalities. The systems are functioning optimally.
Physical Assessment
The physical assessment does not reveal abnormalities.
Mental Status Exam
The three patients are alert, oriented to time, place and person. The family members have dressed appropriately for the day and season. Their speeches are coherent. All the family members deny experiencing hallucination or delusions. Their judgment is sound, and insight is competent.
Differential Diagnosis
J.M’s diagnosis is alcohol abuse, while L.K’s diagnosis is depression. According to the diagnostic criteria, substance abuse is characterized by substance use in the circumstances deemed dangerous, and involvement in legal issues related to substance use (American Psychiatric Association, 2013). J.M has been involved in a fight while drunk, has been charged for driving under the influence of alcohol and has been dismissed from job severally for failing to report to work due to alcoholism. Based on diagnostic criteria, depression presents with loss of interest in activities, sadness, loss of appetite, lack of concentration and loss of body weight.
Case Formulation
J.M’s has been diagnosed with cancer and marijuana usage. Drug usage could be thought as a way of relieving stressful event of lung cancer. Further, J.M abuse to his wife could be associated with alcohol abuse.
Treatment Plan
The most appropriate treatment is a combination of family therapy and cognitive behavioral therapy (CBT). During the family therapy, the relationship between the various members will be mapped. The existing boundaries will be broken. The therapist will realign the relationship that in the family (Johnsen, & Friborg, 2015). During CBT, J.M’s negative perception about cancer will be discouraged. L.K’s negative view of her husband’s cancer and the family’s financial status will be replaced with a possessive view about the issues (Becvar, & Becvar, 2017; Weitz, 2015).
Part 2: Family Genogram
The genogram below represents the three generations for J.M and L.K’s family. All the individuals represented are alive. L.K’s mother was diagnosed with depression, and her father was diagnosed with schizophrenia.