Assignment: Practicum – Assessing Client Progress
Assignment: Practicum – Assessing Client Progress
To prepare:
· Reflect on the client you selected for the Week 3 Practicum Assignment.
· Review the Cameron and Turtle-Song (2002) article in this week’s Learning
Resources for guidance on writing case notes using the SOAP format.
The Assignment
Part 1: Progress Note
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):………THE WEEK 3 ASSIGNMENT IS ATTACHED
BUY A PLAGIARISM-FREE PAPER HERE
· 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.)
· 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 (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
Learning Resources
Required Readings
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)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780) Assignment: Practicum – Assessing Client Progress
Required Media
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.
Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.
HERNANDEZ CASE STUDY 2
The Hernandez Case Study
Part 1: Comprehensive Client Family Assessment
Demographic information
Juan Hernandez Junior is an 8-year-old, Latino, male.
Presenting problem
Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.
History or present illness
Parent’s reports Hernandez has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged in 2010.
Past psychiatric history
Parents report that Juan Jr. has been of sound psychiatric health.
HERNANDEZ CASE STUDY 3
Medical history
Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.
Substance use history
Both parents have no history of substance abuse nor does Juan Jr.
Developmental history
Parents reports no delays
Family psychiatric history
Parents report no psychiatric problems in their family history.
Psychosocial history
Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.
History of abuse/trauma
Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.
Review of systems
Gen: Has no fever, night sweats, heat intolerance, weakness or fatigue.
HERNANDEZ CASE STUDY 4
Head: No migraine headaches reported.
ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty
Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.
Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, and hypertension.
GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, and change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.
GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.
MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.
Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair. Assignment: Practicum – Assessing Client Progress
Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.
Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.
Physical assessment
Vital Signs:
HERNANDEZ CASE STUDY 5
47 Height: inches
Weight: 129lbs
Temp: 37 0C.
RR: 16
BP: 120/59
Pulse: 79 BPM
Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.
Mental status exam
The whole family comes to the appointment since they should do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.
Differential diagnosis
The parents grew up too fast and are projecting their feelings on their children.
Diagnosis
Anger Management issues
Case formulation
The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27-year-old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he should do
daily. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend.
HERNANDEZ CASE STUDY 6
On the other hand, Elena is a 25-year-old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.
Treatment plan
Treatment Goals
The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family come to terms with the situation at hand. Assignment: Practicum – Assessing Client Progress
Estimated Completion: 3 Months
Objective #1
The parents will be able to discipline their children effectively and using safe options.
Treatment Strategy / Interventions: This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting
limits like taking away their privileges and using time-out. This can only be successful if the parents fully understand the age appropriate behavior of each stage s they do not cross boundaries and punish them unnecessarily.
Estimated Completion: 3 Months
Objective #2
In the end, the parents should be able to find child development techniques that will boost their children’s self-esteem and ensure they have a strong sense of confidence. They should also be able to manage their frustrations as a family.
HERNANDEZ CASE STUDY 7
Treatment Strategy / Interventions: Through role playing, both the parents and the children are able to find a way to understand the feelings of the other so they can rectify any issues they might have had. This will help ensure order at home is maintained without the need for discipline and that the parents do not put unrealistic expectations on their children.
Estimated Completion: 3 Months
Social Support system:
Friends and family
HERNANDEZ CASE STUDY 8
Part 2: Family Genogram includes Juan Hernandez Junior’s family.
Paternal grandparents’ maternal grandparents
Hernandez’s uncles Hernandez’s father Hernandez’s mother Aunt
His brother Hernandez Hernandez’s sister
Sister in-law
His nephew
HERNANDEZ CASE STUDY 9
Reference
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.
Assignment: Practicum – Assessing Client Progress
