wk 5,7.8 Prac

Practicum-Assessing Client Progress

Student Name

Institutional Affiliation

Practicum-Assessing Client Progress

Part 1: Progress Note

Treatment Modality and Efficacy of Approach

Hanah was well educated on the treatment plan and the cause of the voices she is hearing. Successful correspondence with pt. was ensured by avoiding confusing medical terms or language. The structural psychotherapy approach was used for this patient to improve her interactive abilities. The therapeutic approach in this case helped Hanah to understand the hallucinations she was undergoing and how they could be managed.

Progress and Modifications of the Treatment Plan

The treatment plan was improved, and Hanah anticipates attending therapy sessions. She complains of hearing imaginary voices and this is attributed to hallucinations. The treatment plan is revised since she is yet to register improvement. The new treatment plan is given to her, and she is receptive towards the idea.

According to her medical history, she has been on hypothyroid. However, she was placed on Lithium 300mg orally two times a day, seroquel 100 mg orally 2 times a day, and synthroid 100 mcq/day. She verbally tolerated the medication as it would help in reducing the hallucinations. She was also educated on how it will ‘stop’ the voices she was hearing without knowing where they came from.

Clinical Impressions Regarding Diagnosis and Relevant Psychosocial Changes

Hanah verbalized efficiency of the therapy session since hallucinations had reduced. She was hearing the voices less frequently now. She also verbalized her enthusiasm and plan to be consistent with the treatment plan, adhere to the medication, and avoid drug relapse.

Safety issues, Clinical Emergencies, and Actions Taken

No safety crises or issues noted at this point. No contemplation of suicide or personal harm. She also states that staying away from drug abuse has helped to reduce hallucinations. The voices she was hearing are disappearing.

Medications Used

· Lithium 300mg orally two times a day.

· Seroquel 100 mg orally 2 times a day.

· Synthroid 100 mcq/day

Treatment Compliance, Clinical Consultations and Collaboration

Hanah has attended all sessions and shows commitment to the treatment plan by avoiding drug abuse. She was also scheduled for mental assessment by a psychiatrist. The therapist consulted the psychiatrist over phone for evaluation of the patient and collaboration on a treatment plan. Hanah shows commitment to the prescriptions.

Therapist’s Recommendations and Referrals

Therapist prescribed CBT for Hanah and also referred her to a psychiatrist for better assistance as she showed signs of developing depression.

Termination/Issues Relevant to the Termination Process

Termination not viable since Hanah is covered under medical coverage and shows commitment to the sessions and treatment plan. She also signed an informed consent showing she knew the role she had to play for the sessions to be successful.

Information Concerning Child Abuse

No case of child abuse reported.

Clinical Judgement

Hanah is responding adequately to the treatment plan as she does not experience any physical hallucination or further symptoms. She needs to stay consistent with the therapy sessions and attend her psychiatric appointments.

Part 2: Privileged Note

Hanah has attended all her scheduled therapy sessions. She remains alert and oriented. However, she reports that she hears loud voices not sure what are they saying. She hears Voices are almost all-day and night. Voices are not command. Denied for any visual hallucination or denied for any suicidal thoughts, denied for additional symptoms. This shows that she is improving and responding well to the treatment plan.

There is some information that can be included in the privilege note but not in the client’s progress note since such information is confidential to the patient and can only be included for valid purposes.

Privileged notes are used in such cases as when a patient wants the information to present to their boss as proof but without uncovering the medical condition or the treatment plan about the patient. Further, privileged notes are used to document any of the patient’s unnecessary feelings, thoughts, or events which are inconsequential.