Assessing Client Family Progress

Assessing Client Family Progress

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Learning Objectives

Students will:

· Create progress notes

· Create privileged notes

· Justify the inclusion or exclusion of information in progress and privileged notes (SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE)

· Evaluate preceptor notes

To prepare:

· Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),

The Assignment

Part 1: Progress Note: Practicum – Assessing Client Family Progress

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: Practicum – Assessing Client Family Progress

· 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. (SEE ATTACHED WEEK 3 NOTE),

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.

HERNANDEZ FAMILY CASE STUDY 2

Part 1: Comprehensive Client Family Assessment

Demographic information

Juan Hernandez Senior is a 27-year-old Latino man who is married to a 25-year-old Latino woman, Elena Hernandez and both have a family (Hernandez family).

Presenting problem

Junior Hernandez Senior described that his parents used to punish him while he was a kid and that he ended inheriting the behavior of punishment his children from his parents. The punishment was so painful to him since he would be made to hold the heavy books form encyclopedia. Juan Hernandez Senior explains that he inherited this behavior of disciplining his children from his parents. The social work has been sent to Juan Hernandez Senior since the children are complaining of how painful this punishment has been to them, especially to Juan Hernandez Senior.

History of present illness

The father of Juan Hernandez senior, Hector reports that Hernandez has not drug abuse problem though he has had criminal history of petty theft.

Past psychiatric

The father reports that Hernandez senior has been of sound psychiatric health status.

HERNANDEZ FAMILY CASE STUDY 3

Medical history

The father reports that Hernandez senior has been okay health-wise. However, her wife, Elena Hernandez, has recently been diagnosed with diabetes.

Substance use history

No history of substance abuse has been reported for the parents of Hernandez senior.

Development history

The father reports that Hernandez senior experienced no delays in development.

Family psychiatric history

No psychiatric issues in the family history of Hernandez senior’s parents

Psychosocial history

Hernandez Senior is described as a sociable person who was able to interact in friendly manner with his parents and friends.

History of abuse/trauma

No other form of abuse has been reported on Hernandez senior apart from the punishment of holding heavy books that his parents used to institute on him. As such, he did not inherit any other form of punishment from his parents.

HERNANDEZ FAMILY CASE STUDY 4

Review of Systems:

Physical assessment

Juan Hernandez Senior is medium-slim Latino male who seems to be cheerful and smart all the time.

Mental status exam

The counseling has to involve the whole family: Hernandez senior, Elena Hernandez, Hernandez Junior, and Alberto Hernandez. This is because there is need to address all the root causes of the current problem (Wheeler, 2014). Hernandez Senior seems to be a bit ready to learn how he can overcome the habit that he inherited from his parents of giving his children torturing punishment of holding heavy encyclopedia books. This is because he does not see why his children should suffer the same way he used to suffer while undergoing the same punishment. He is, therefore, ready to be helped how he and his wife can stop this habit and improve their relationship with their children.

Differential diagnosis

Both Hernandez Senior and his wife, Elena Hernandez married at very young age and inherited many behaviors from their parents, including the way to raise and discipline children.

HERNANDEZ FAMILY CASE STUDY 5

Diagnosis

The diagnosis is to do with how Hernandez senior and his wife can change their behavior which they inherited from their parents on how to discipline their children.

Case formation

A social worker will try to assess why Hernandez senior inherited the behavior of disciplining his children from his parents and how this behavior can be stopped. Hernandez Senior is a casual worker at the airport and sometimes drinks 6-8 beer on weekends. He has had petty criminal record while at tender age. His wife has had no criminal or drug abuse record.

Treatment Goals

Goals: The goals for treatment is to help Hernandez Senior to do away with the behavior he adapted from his parent of punishing his children the way he does and also adapt new positive ways of disciplining them in the way that will improve the relationship with his children.

Treatment strategy/interventions: The first treatment strategy or intervention will involve removing the anger that Hernandez Senior underwent through when enduring the harsh punishment from his parents. The other treatment strategy will involve teaching Hernandez senior and his wife, Elena Hernandez, the positive and safe skills which are effective in disciplining their children. This will improve the parent-child relationship.

Estimated completion: 3 months

HERNANDEZ FAMILY CASE STUDY 6

Part 2: Family Genogram

Children

Juan Hernandez

Other children

Juan’s mother

Juan’s father

Juan Hernandez

Children:

Juan Hernandez Junior

Alberto Hernandez

Elena Hernandez

HERNANDEZ FAMILY CASE STUDY 7

References

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.

MENTAL HEALTH CLIENT PROGRESS AND PRIVILEGE NOTE 2

Comprehensive Client Family Assessment: Progress Note

Date of Exam: 15/10/2017

Time of Exam: 2:00 PM

Juan Hernandez is an eight-year-old boy, Juan shows a lot off change. Juan does not exhibit any symptom which can be described as mental anxiety or even depression. He seems to be having a future disturbance which has lead the family in attending mental agency for children counseling such brought of a child may lead to depression to the child which may even become fatal in future. Juan is living well, he has no any complication in his body, and the parent may be suffering from depression which makes them punish their child in such a way. The parents seem to be mentally weak and do not understand their child. The parents may even be suffering from certain guilt.

The content of therapy: Juan and his parents were advised to visit a local community mental agency, this is because of the parent physical punishment to Juan who seems to be harmless and is of good health both physically and mentally. The punishment may lead to depression to healthy Juan, which can lead to fatal though. The parents have severally been punishing their child Juan, with kneeling down while holding two encyclopedia books. The parents may be having some depression or some guilt which is affecting them to punish their child.

MENTAL HEALTH CLIENT PROGRESS AND PRIVILEGE NOTE 3

Therapeutic Interventions: the important therapeutic techniques used in the therapy session was to help in finding the areas which have difficulties, where there will be the development of

coping skills and also a way of managing stress. The session was to have the parents develop self-awareness and compassion. The parents will have to be able to see their selves and the child in a more positive way. The child should be able to forget the past and forgive his parents and be able to move on with his life in a more positive way. The child also needs to be able to make positive remarks at the end of the session and also be able to cope up with stress life.

Mental Status: the child has no sign of irritable or distracted, the patient has a full communication, he is always well groomed and appears to be normal. He also exhibits a normal speech rating, volumes and also its articulation is coherent and also spontaneous. He has an intact language speech. He has normal l mood with no signs of depression; he also does not have mood elevation as there are no physical changes to him, as he also eats as normal. All his physical and mental tests are normal. The parent has bizarre behavior, in a psychotic process, they seem to have depression lead by their quick marriage which they have now directed their depression to their child. There cognitive functioning and the fund of knowledge I not positive, but their son cognition is positive. The son is average, but with the risk of having depression, the parents seem depressed and not happy.

Diagnoses: below are the diagnoses which are based on the current information; the diagnosis can change with a change to any additional information.

MENTAL HEALTH CLIENT PROGRESS AND PRIVILEGE NOTE 4

The link treatment plan is depression, with the parents.

In the short term goals, the parents may have the depression symptom in less than 50% in a month. The target day is on 15/11/2017.

There was progress as the parents need more family together, they need to celebrate their life as parents and Juan as their son. They also need to have a social support from their family and friends.

Privilege Note

The patient’s estimated medical checkup of physiological functioning appeared relatively unhealthy due to diabetes, however, he showed short-lived anger management issues to stressful events. The patient demonstrated no slight difficult in relational and working functioning. The patient’s affective states appeared agitated and depressed. He has no drug-related issues but he has engaged in criminal history. The patient has the history of involvement in punishment. Both parents were involved in the appointment. It was noted that Juan has anger towards counselor

The main themes of the psychological session were: effective and safe discipline skills, developing age-appropriate behavior, boosting self-esteem, developing the sense of confidence and managing the frustration. The main therapeutic interventions designed included: parenting Assessing Client Family Progress

MENTAL HEALTH CLIENT PROGRESS AND PRIVILEGE NOTE 5

sessions for parents to teach effective discipline skills, role-playing where both parents and the patient are involved in understanding feelings of each other and interpretations of barriers

regarding enjoyment. It was noted that the patient continues to make good progress upon understanding anger management. Developments are in progress in family and relational aspects. They are also expected to manage frustration as a family. Treatment will continue as indicated.

The psychotherapy notes capture the data of the patient, the type of assessment carried out and the plan laid for the therapy (DHHS, 2002). The note can have a different format, use SOAP which capture statement, objective data, assessment and plan. Psychotherapy notes exclude the time duration of the counseling, the modalities of treatment and results of tests. This information is excluded to guard patient safety and to protect sensitive information. My preceptor uses the psychotherapy notes are personal notes as they are intended for the therapy session. Additionally, they have little help to medics who are not involved in the therapy (Abeles, 2011).