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 Pr
Running head: Assignment 2: Practicum 0
Assignment 2: Practicum – Assessing Client Progress
NURS 6640
There are differences regarding what is documented in the patient’s record and the scribed personal observations of the psychotherapist. Indeed, this paper will explore the soap note by utilizing information from week three. Also, there will be a week-three privilege note constructed, along with a discussion of the differences of the privilege note and the notes made in the patient’s medical record.
Week Three SOAP Note
12/12/19 14:00 (S) "I feel depressed, stressed anxious, and unbalanced." Also, patient stated, "I get shaky and sweaty." Recent History: The patient reports problems in his marriage, intimate relationships, and with others including paranoia, reduced sleep and appetite, worried about finances, excessive talking. Personal History: The patient had mental treatment at Hospital USA decade ago. Previous diagnoses include bipolar disorder, schizophrenia disorder, and history of substance abuse. The patient was raised by both parents, including one older brother, and a younger sister. The patient stated that his family moved around a lot, and he "never was stable in school. Also, patient was on psychiatric medication as a child, and witnessed violence between his parents, and violence on the streets where he grew up; additionally, the client reports witnessing a friend overdose on drugs. The patient stopped attending school around age 13 after he was "put out by school security." The patient left home at age 13 due to his mother not providing – "she was a heroin addict." (O) Flight of ideas with rapid, loud, paranoid, persecutory, trouble concentrating pressured speech, and frequently labile mood (A) Bipolar 1 disorder, depressed, severe [F31.4, DSM code] and Generalized Anxiety Disorder [F41.1, DSM code]. Clinical impressions: Rule out Bipolar I given the hypomanic symptoms. (P) Rescheduled for 01/12/20 @ 2 p.m.; Prognosis fair, due to the patient's current hypomanic state.
Patient to see Dr. N after therapy for psychotropic medication session to review the current medication regimen of Prozac and Trazadone. Referred to NAMI for family therapy. Next session: Continue cognitive behavioral therapy sessions and assign reading homework: Cognitive-Behavioral Therapy Program–Workbook by Grant, Donahue, and Odlaug) (Cameron & Turtle-Song, 2002).
Part Two: The Privilege Note
12/12/19 14:00: During the meeting with the patient, I noticed that the patient was more manic than usual, which leads me to believe he may not be completely compliant with his medication regimen. Moreover, the patient's marital problems may also be exacerbating his bipolar condition and increasing his insomnolence; thus, there may need it will be essential to review the effectiveness of the current psychopharmacology in the next session. In summary, I believe that the client has plateaued his motivation toward his therapeutic goals; nevertheless, I will defer confronting this concern until after reviewing the progress with the patient at the end of the next meeting (The Differences Between Psychotherapy Notes and Progress Notes, 2018).
Privilege Note Versus Progress Note
Privilege notes are the personal notes of the psychotherapist's observations and impressions of the patient. The privilege note will include items such as the psychotherapist's hypothesis, observations, thoughts, and feelings regarding the patient's unique condition. The privilege notes serve as an essential tool that the clinician refers to when determining an effective treatment plan (The Differences Between Psychotherapy Notes and Progress Notes, 2018).
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Also, privilege notes are kept separate from medical records and billing information, and providers must have the patient's authorization before sharing the notes; paradoxically, the patient does not have a right to access the privilege notes (The Differences Between Psychotherapy Notes and Progress Notes, 2018).
Preceptor’s Privilege Notes
The preceptor utilizes privilege notes in her everyday practice. Indeed, the preceptor will scribe observations and opinions immediately after the meeting. The preceptor takes no more than a few minutes to make the privilege note, and she will refer to them in the next meeting (Cameron & Turtle-Song, 2002).
Conclusion
The clinician must understand the nuances of patient documentation. Indeed, documentation in the patient’s medical record contains data pertinent to the direct care of the patient. In contrast, the privilege note serves the clinician as a personal record of impressions and observations. Ultimately, both types of notations serve to enhance the patient’s overall standard of care.
References
Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development, 80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x
Psychotherapy Notes and HIPAA. (n.d.). Retrieved January 12, 2020, from https://psychcentral.com/lib/psychotherapy-notes-and-hipaa/
The Differences Between Psychotherapy Notes and Progress Notes. (2018, June 8). ICA Notes. https://www.icanotes.com/2018/06/08/the-differences-between-psychotherapy-notes-and-progress-notes/
References
Cameron, S., & Turtle-Song, I. (2002). Learning to Write Case notes Using the SOAP Format. Journal of Counseling & Development, 80(3), 286. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x
