Journal Entry
nurseo
SAmple.pdf
RUNNING HEAD: PROGRESS NOTE 1
Lisa Bell
Progress Note
Week 7
NURS 6650- Practicum
Walden University
October 2019
PROGRESS NOTE 2
Progress Note
Part 1
The purpose of this paper is to write progress note and a privileged psychotherapy note
regarding the family assessed in a prior comprehensive assessment.
Clients: A.W., 31 year old Caucasion female, P.G. 47 year old Latino male.
Diagnosis (DSM-5): Relationship distress with an intimate partner, Generalized Anxiety
Disorder (GAD) (American Psychiatric Association, 2013).
The clients present with relationship difficulty due to their personal mental health issues,
history of negative relationships, and wishes to learn hope to manage conflicts and evaluate the
future of their relationship.
Treatment modality used and efficacy of approach: Family therapy session with a Cognitive
Behavioral Therapy approach, progress thus far has been minimal, with realistic expectations
identified, and one temporary breakup in their relationship.
Progress and/or lack of progress toward the mutually agreed-upon client goals:
The client goals were to evaluate if their relationship was worth saving or if it was
mentally and physically exhausting to be in a partnership. They desired to have a healthy
relationship with each other and be a strong example for their small formattable children. Stress
of work, school, and social obligations has exacerbated A.W.’s anxiety and manic state of
bipolar disorder, and this has caused disruption in their relationship, and negatively to the point
that P.G. decided to take a break would be the best for a short time.
Modification(s) of the treatment plan that were made based on progress/lack of progress:
Based on the lack of understanding of psychological turmoil that A.W. is suffering from, their
PROGRESS NOTE 3
treatment plan was modified to enhance their pattern of thought and integrate mindfulness CBT.
Mindfulness CBT teaches how to increase one’s presence in a relationship and the ability to
relate to their partner, as well as decreased associated anxiety, which had impair relationships as
well, and disrupt its balance (Gillihan, 2017).
Clinical impressions regarding diagnosis and or symptoms: Increased individual anxiety,
manic episode of bipolar disorder, both impact their relationship and increase overall anxiety.
Inability to effectively cope with unexpected stress and immediately revert to ending the
relationship instead of understanding the thoughts, behaviors, and emotions of the counterpart. .
Relevant psychosocial information or changes from the original assessment: The couple
broke up their relationship for three days after an intense conversation, and inability for P.G. to
cope with A.W.’s anxiety and manic mood. They rekindled their relationship after discussing
their desired to still be together and their love for each other. No other changes occurred from
the original assessment.
Safety issues: No significant safety issues noted.
Clinical emergencies/actions taken: No clinical emergencies noted.
Medications: A.W. is prescribed Latuda, Lamitcal, and Propranolol. P.G. is prescribed Plavix,
Coreg, and Prozac
Treatment compliance/lack of compliance: Compliant with medications. Noncompliant to an
extent with mindfulness techniques and CBT therapy modules.
Clinical consultations: Individual therapy in addition, with review of medication management
with an PMHNP for both clients, and referral to couple therapy specifically.
PROGRESS NOTE 4
Collaboration with other professionals: Referral for a therapy that specializes in couple
therapy, and PMHNP for continuation of medication management.
Therapist’s recommendation: Continue family therapy, set up couple therapy and
appointments with PMHNP to adjust or evaluate mediation management and effectiveness. Use
mindfulness techniques such as acknowledging the partners feelings, and writing down thoughts
when anxiety increases or unexpected outcomes occur.
Referrals made/reasons for making referrals: Individual sessions for both partners, especially
A.W.
Termination/issues: N/A
Issues related to consent and/or informed consent for treatment: Patients made aware of
treatment plan, consents to treatment with counselors, coping mechanisms, referral to individual
therapist sessions and PMHNP for further medication management.
Information concerning child abuse and/or elder or dependent adult abuse: Client’s
informed of negative impact on young children to be involved a unstable relationship, with high
anxiety and history of domestic violence. Informed client’s that any confidential information
regarding the impaired safety of a child or elder will be reported.
Information reflecting the therapist’s exercise of clinical judgment: Clinical judgement of
these clients is that there is a lack of relationship support for the two of them to learn from or
seek for healthy boundaries. Both of them had divorced parents and have had several failed prior
relationships, therefore developing a healthy supportive and strong relationship is difficult.
When A.W.’s anxiety or mood disorder changes, she must work on her coping mechanisms and
controlling her emotions and anxiety, and P.G. must work on accepting her psychological
PROGRESS NOTE 5
rollercoaster, and learn coping skills and acknowledge alternative outlets, if they both wish to
pursue a healthy relationship.
Part 2
Privileged Note
This couple is seeking either confirmation that their relationship is not meant to be or
hope through therapy that it will actually work out. However, with their past record of both
having unsuccessful relationships, and having broken up multiple times over the past two years,
despite their effort, they will be their own demise. They both must old accountability for their
own actions and listen to one another in order to formulate a healthy relationship and be a good
example for the children in their lives. It is difficult to communicate with someone that is not
willing to listen or change, or be mindful other how their actions affect the other person. It
seems as if P.G. does not want to entertain the stress of A.W.’s mental disorders, and is easily
disengaged when her emotions and anxiety are high. A.W.’s if putting forth more effort into
making the relationship “work” and this can get exhausting if she continues despite the true
intentions or desires of P.G.
Privileged notes or psychotherapy notes are additional notes that are not part of
required medical record and do not contain medical information or identifying information. The
laws of HIPAA allow these notes to disclose the “therapist’s personal notes, such as thoughts and
feelings about a case, theoretical analysis of sessions, or notes in preparation for consultation”
(Griswold, 2017). Privileged notes are still confidential legally and must be securely kept, but
are not a required aspect of therapy evaluation. One would not include personal thoughts or
PROGRESS NOTE 6
feelings, hunches or hypotheses into a progress note. As well privileged notes can be a reminder
of a session, a self-consultation without detailed information or violating HIPAA.
The preceptor that I am currently with does not use privileged notes, only progress notes
that are shared within the medical record of each client. Progress notes are used for
collaboration and continuation of therapy to enhance the client’s care. Progress notes are already
time consuming and additional privileged notes are not necessary to fulfill the requirements,
especially since so many groups rotate through the practice.
PROGRESS NOTE 7
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Gillihan, S. (2017). 8 ways CBT can improve your relationship. Psychology Today
March 2017. Retrieved from
https://www.psychologytoday.com/us/blog/think-act-be/201703/8-ways-cbt-can-improve
-your-relationship
Griswold, B. (2017). Progress notes vs. psychotherapy notes: Do you know the
difference? Retrieved from
https://navigatingtheinsurancemaze.com/articles/progress-psychotherapy/
