My client`s diagnoses were: Axis I: 1)
Other Specified persistent mood disorders, F34.89 (ICD-10) (Active)
Generalized anxiety disorder, F41.1 (ICD-10) (Active)
BMI is 38.1 and considered as clinically obese.
The patient will benefit from Psychopharmacology and ongoing supportive psychotherapy.
Weight Issue: The client was counseled regarding her weight. She was counseled regarding overcoming barriers to weight loss. She was counseled regarding behavioral management activities that will help to promote weight loss.
The client`s weight will be monitored during follow up visits and counseling will continue during such times.
– The signed consent to start the following meds:
-Start Latuda 20mg1 tablet PO q HS x 7 days then 2 tablets q HS x14 days. This medication is for mood stabilization and will help to manage the client`s mood disorder i.e. Bipolar
-Start Lexapro 20 mg 1 tablet PO QD x 7 days, then ½ tablet QD x 7 day. This is an antidepressant and helps to manage the client`s depressive symptoms.
-The client was counseled on importance of compliance with psychotropic medication and therapy.
-The client has been scheduled for a follow up visit to the clinic in 2 weeks
Part 1: Progress Note
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
Treatment modality used and efficacy of approach
Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—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 (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
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
Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
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 (i.e., 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 from the Week 3 Practicum Assignment.
The privileged note should 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’s progress note.
Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292.
Davidson, J. R., Feltner, D. E., & Dugar, A. (2010). Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs. Primary care companion to the Journal of clinical psychiatry, 12(2), PCC.09r00772.
Mayo Clinic, (2017), Generalized Anxiety Disorder. Retrieved from: https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-causes/syc-20360803
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.
Part I: Progress Note
Treatment Modality: The treatment modality used is holistic which entails a combination of pharmacology, psychopharmacology, and psychotherapy. The efficacy of this modality is effective in addressing the different patient symptoms and weight issues.
Progress Towards the Patient Goals: Client demonstrates positive progress especially in counselling and medication adherence. Patient notes less commitment to behavioural management and especially diet management. Patient rates achievement of her goals as 50%.
Treatment Plan Modification: Based on the progress, treatment modification entails developing daily eating and exercise targets for the client while working with the gym specialist.
Clinical Impressions and Psychosocial Information: Symptoms have improved significantly. The client is more open and interacts with close family members easily. The client is jovial, and the anxiety has reduced. She has also demonstrated improved social cues and a wider emotional expression. Patient has further formed new relationships and is eager to resume work.
Safety and Clinical Emergency: Patient has not experienced any safety issues or clinical emergencies and has not used other medication besides the one prescribed at the hospital.
Medications: Based on the signed consent, the patient uses the following medications
- Latuda 20mg1 tablet PO q HS x 7 days, then 2 tablets q HS x14 days for mood stabilization.
- Lexapro 20 mg 1 tablet PO QD x 7 days, then ½ tablet QD x 7 days for depressive symptoms.
Treatment Compliance: Client shows medication adherence with regards to dosage and time of intake. She also attends all her counselling sessions.
Clinical Consultations and Collaboration: Client has maintained clinical consultations which are beneficial to her health. She contacts the physicians and counsellor when she has a question. Client adheres to the therapist’s recommendations such as ways to overcome anxiety and on behavioural management.
Referrals: Referral to a dietician for developing a meal plan for the weight issue. The referral is centred on the client’s slow response to behavioural management and changes.
Termination Issues: No termination issues reported such as loss of insurance.
Consent Issues: Patient consents to the medication and therapy. No reported issues.
Abuse: No child abuse or adult abuse reported.
Clinical Judgement by the Therapist: Therapist demonstrates good clinical judgement as reflected on the referral and recommendations on ways to address the mood-related challenges and weight issues.
Part II: Privileged Psychotherapy Note
According to the Health Insurance Privacy and Portability Act (HIPAA), psychotherapy notes document or analyze the conversation contents in a counselling session for an individual, family, or group. They are separated from the rest of the patient’s medical records thus should not include medication monitoring, frequency and modalities of the treatment, and clinical tests results (Wheeler, 2014). For this patient, the psychotherapy note will include the following four items.
Observations: This will entail the overall perception of the patient from the therapy sessions. Also included are unique details that may be of importance in enhancing the individual recovery (Wertheimer, 2016). Observations during the therapy sessions include the patient’s moods and anxiety and perceptions towards the sessions. These observations would be essential in developing a profound treatment plan.
Hypotheses: These are proposed explanations or suppositions towards the patient’s health. The hypotheses will also be based on the patient’s symptoms where the explanations regarding the individual’s condition will be informed by evidence and literature.
Questions for the patient: These will involve the specific questions that will be used in the therapy sessions. Examples for this patient will include the level of mood swings after taking the treatment any new feelings including irritability, and sadness. Also included in the questions are a recurrence of dysphoric moods and suicidal ideation episodes.
Feelings and thoughts regarding the therapy: These are perceptions related to the therapy sessions and patient’s progress. Information under this category will include the reduction of symptoms and mood changes. Also, the hypotheses will be connected with the information provided by the patient during the sessions.
The above items should not be included in the progress note which is a recommendation by HIPAA. Also, this information is for the therapist and should not be shared based on its sensitivity. According to the privacy rule by HIPAA, psychotherapy notes should not be disclosed.
My preceptor uses privileged notes and includes details about my progress and achievements. She also includes specific questions, observations, and unique feelings and perceptions regarding my understanding and progress. This allows for developing the next milestones and establishing areas of improvement.
Wertheimer, M. (2016). Remember to Keep Psychotherapy Notes Separates from Patient’s Medical Records. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.10a19
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. Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242), Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)