Assignment: Practicum – Assessing Client Progress

Assignment: Practicum – Assessing Client Progress

A Sample Answer For the Assignment: Assignment: Practicum – Assessing Client Progress

Title: Assignment: Practicum – Assessing Client Progress

Assessing clients is among the processes of determining the progress of therapy. According to various stakeholders, the patient’s medical care, treatment plans, and other pertinent information are shared using the progress note while privilege note forms an important assessment of a patient from a personal perspective. The purpose of the present order is thus to formulate a progress note and privileged note regarding a patient that was assessed in the course of the present course without violating the HIPPA.

Part 1: Progress Note

The patient is a 73 years old African American male admitted after initially receiving discharge from a different local hospital. He presented with increased psychosis alongside auditory hallucination. The patient demonstrated a history of multiple hospitalizations though he refused to divulge details about them. Nevertheless, his initial diagnosis was psychosis alongside multiple hallucinations. He reported that he can hurt other people and himself as well. Before checking into the hospital, he reported planning to hurt himself using an ice pack. He revealed that the auditory hallucinations had been telling him to hurt himself. The patient also has a history of refusing medications. He could not remember the onset of the symptoms. He reported abusing cocaine and cigarettes without specifying the latest indulgent.

Treatment Modality Employed and Its Efficacy – Cognitive Behavioral Therapy: The patient showed a history of non-compliance with medication even as he had chronic mental illness. Cognitive Behavioral Therapy was used in order to evaluate the perceptions, reasoning, and beliefs of the patient. Further, the CBT helps a therapist to ensure the promotion of alternative methodologies that they could use to cope with the demonstrated symptoms. Thus, the objective of using this modality is to ensure that the therapist alongside the patient arrive at the right treatment plan (Robertson, 2018). Regarding the efficacy of the CBT modality, the patient was more interested in the suggested plan, which was consistent with the desires of the patient, the counselor as well as the psychiatrist.

Progress towards Goals: The Cognitive Behavioral Therapy proved a masterstroke as the client accepted to alter his initial behavior. He accepted to start on the suggested antipsychotics during the re-assessment session. He had sessions where his alcohol consumption and drug abuse behaviors were challenged and his emotions regulated. He is undertaking all the pertinent activities requested by the counselor and has follow-up sessions with his psychiatrist at least twice a week.

Treatment Plan Modification: The client was started on Clonazepam, 1 mg tablet BID in order to manage his anxieties during the treatment period.

Clinical Impressions: Sivanesan, Gitlin, and Candiotti (2016) posited that opioid-induced psychosis with hallucination occur as a

result of uncontrolled substance abuse. The condition is manifested through the presence of ether hallucinations or delirium or both. During such instances, an individual takes leave of reality by firmly believing in certain false beliefs yet the evidence contradicts them. In most cases, the existence of mental illness becomes a predictor of substance abuse and psychosis develops when one overly intoxicates themselves.

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Psychosocial Information or Deviation from Original Plan: None.

Safety Issue: None. He reports reduced hallucinations with elimination of the urge to harm himself and others.

Clinical emergencies/ Action Taken: None

Medication:

Quetiapine 200 mg oral tablets once a day for mood/sleep/anxiety

Mirtazapine 15 mg oral tablets, at bedtime, daily, for anxiety

Treatment Compliance: The patient showed willingness of try the treatment after the CBT.

Clinical Consultation: None

Collaboration with other Professionals: None

Therapist recommendation: The therapist recommended that the patient undertakes a peer-support therapy wherein the patient will use the sessions to alleviate the effect of voice. The participation in the self-help group will enable the patient to assume responsibility for the hallucination, acknowledge and then overcome their voices. Using the peer support group, the patient is expected to control their symptoms aptly.

Referrals/ Reasons for referrals: After discharge, the patient will be seeing a counselor to help integrate him into the society gently. Also, he will be visiting a psychiatrist and a therapist to help guard against relapse.

Termination/ Relevant Termination Issues: None. The patient was able to complete the therapies as scheduled.

Consent/Informed Consent Issues: The patient was offered everything related to information consent on admission. He was given he informed consent form and his opinion sought in all the treatment modalities. Thus, no informed consent matters arose during the therapy.

Information Regarding Abuse: None reported.

Therapist’s Exercise of Clinical Judgment: The therapist needs to consider others first before themselves hence the essence of self-awareness in therapy sessions (Spendler & Pilipis, 2015). Thus, the therapist will always act in the best interest of the client and not manipulate them into satisfying the former’s needs.

Part 2: Privilege Note

Privilege note encloses a patient’s information with regard to individual or group sessions, assessment, and available treatment options or care plan. Obtaining and the documentation of the informed consent form helps in boosting the relationship between the therapist and the patient especially when managing a psychotic disorder with auditory hallucination and suicidal thoughts. Here, private sessions between the counselor, and the patient, or group or family counseling sessions are separated from the patient’s primary medical records, as this information is confidential and only required by the therapist to help them organize and prepare themselves appropriately in developing the patient’s treatment plan (Wheeler, 2015). The privilege notes are sometimes composed of psychotherapy hypothesis, questions relating to the therapy session, and general observation of the whole process.

All the information in the privilege note is usually confidential and should not be documented together with the patient’s medical records as they are only to be used by the therapist as an added tool in formulating the patient’s treatment plan (Hayward, 2018). During my psychiatry clinical rotations, my preceptor utilized the privilege notes in understanding the patient progress with therapy and even asked him how his last session was, and what he would want changed to help in the management of his condition.

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed
• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource