Assessing Client Progress
NURS 6640
Walden University
Progress Note
Client Name: JS
Diagnoses (DSM-5): Major depression disorder, recurrent, moderate severity with schizophrenic episode.
Date: 10/13/18
The patient was presented to the day center with signs and symptoms of depression with schizophrenic behavior and use of illicit drugs in the past, therefore the use of behavior modification treatment approach will be beneficial. The Cognitive behavioral therapy (CBT) will be the best treatment because it helps in assisting the patient, on how he/she views himself or herself, the problem, and the available resorts (Wheeler, 2014, p.329). The incorporation of cognitive therapy was effective because there was decrease in schizophrenic behaviors and, also in depressive moods, thus, led to progress in patient’s goals by mutually accepting the treatment plan ahead in medication adjustment and some exercises. Few modifications were made during treatment, such as exercising, eating healthy meals and taking medication at appropriate time. No relevant psychosocial information or changes from initial assessment. Patient has not had any current clinical emergencies, indicating diagnosis and treatment of disorder is managed.
The patient is currently on antipsychotic medication which is effective and, a reconsideration of putting him on Selective Serotonin Reuptake Inhibitor (SSRI) to manage his depression, which was helpful in the past. This medication has seen to help in decreasing patient’s psychotic behaviors and therapist in collaboration with the Psychiatrist in putting him on SSRI regimen. With the assistance of his mom and caregivers, patient is complying with treatment and improvement in symptoms is seen. So engaging patient more in cognitive therapy will assist in bringing self-worth to the patient and ensuring effective management of care.
Privileged Note
In a privileged note, it encloses information regarding a patient during their individual/group sessions, assessments and treatment options and plans. Obtaining and documenting the informed consent in lure of the professional relationship between the therapist and patient diagnosed with major depressive disorder, recurrent, severe moderate severity with schizophrenic episode is usually processed through recording. Here any private counseling session, or a group, joint or family counseling sessions are separated from the patient’s primary medical record because is not a progress note, it only assists the therapist in organizing himself/herself in treating the patient (TheraNest Staff, 2018). Privilege Notes sometimes consist of the psychotherapist hypotheses, observation, questions or any thoughts or feelings relating to the therapy session (2018).
Again, all items seen in privilege notes should not be in medical records because it is only for the therapist use. During my clinical rotation, my preceptor did make use of privilege notes in which she asked the patient how their last session was, and what he would need from her to better manage his prognosis that will lead to an effective treatment plans.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
The Differences Between Psychotherapy Notes and Progress Notes. (2018, September 18). Retrieved October 12, 2018, from https://www.icanotes.com/2018/06/08/the-differences-between-psychotherapy-notes-and-progress-notes/
TheraNest Staff. (2018, June 11). What are Psychotherapy Notes vs Progress Notes? Retrieved October 12, 2018, from https://www.theranest.com/blog/what-are-psychotherapy-notes-vs-progress-notes/
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.