A 14 year old male African American came in with his mum. He was alert and oriented x3. He was dressed appropriately for the weather and was observed as being hyperactive, restless and irritable. He exhibits symptoms of agitation, feeling of worthlessness, worry, and lack of focus and concentration. Client denies suicidal or homicide ideations, no drug or alcohol abuse, he never been arrested and is not involved in gang activity. He further denies any physical, sexual, or emotional abuse, had never been arrested, and is not involved in gang activity. He further denies any physical sexual or emotional abuse . Client reported that he had an altercation with his mother concerning his disrespected behavior towards her because he rejects any authoritative control and engaged in a disruptive altercation with his mother . He subquently left the home seeking the local police for assistance
Diagnosis:
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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.
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