Wk7Prac.Soap

Introduction

The therapists use the progress note to chart on their interactions with the clients during the therapy session. The progress helps care providers and health workers to communicate and pass on information with transpired during client care. Progress notes help to ensure the safety of the patients and continuity of care. (Okaisu, Kalikwani, Wanyana, and Coetzee, 2014). The component of psychotherapy progress note may include evaluation, diagnosis, objective, treatment modality utilized, time therapy starts/ends, and treatment plan. Health care providers utilize SOAP (subjective, objective, assessment, and plan) format in writing progress notes. The therapist using soap format during documentation helps to communicate precise and legible information. Soap format has critical components: subjective, objective, assessment/diagnosis, and planning stage, which is the treatment decision and diagnosis (Cameron and Turtle-Song, 2002). The practitioner will discuss the interaction with the client during session therapy, utilizing the key components in the progress note used in psychotherapy. 

 Part 1: Progress Note for IA. 

IA is a 15-year-old Hispanic female who presented in the clinic for counseling at week three practicum due to suicidal ideation with a plan. This paper will assess IA progress since initiation of therapy after attempting suicide by overdosing. IA reports extreme anxiety, conflicts, and poor communication with mom. IA reports constant criticism from mom’s boyfriend that leads to frequent fights and outbursts. IA reports not feeling loved. IA reports

symptoms of decreased sleep, decreased appetite, increased anxiety, seclusion in her bedroom, periodic crying spells, and loss of interest in school and social activities. She started street drugs and attempted suicide by overdosing on medication. IA reports a possible trigger for SI was not feeling loved and judged at home and school. IA denies suicidal ideation during the therapy

session and reports no intension in hurting anyone else. IA reports anxiety 10/10. IA reports mom brought her for counseling due to an attempt to overdose. During the assessment, IA was vigilant, aware of her surroundings. IA presented with a normal suitable mood. 

Treatment Modality used and Efficacy of Approach- Pharmaceutical and Cognitive behavioral therapy 

The treatment plan employed in the management of IA is the combination

of medication and cognitive-behavioral therapy. Cognitive-behavioral therapy (CBT) is used in addition to giving client medication or the therapist can use only CBT while gradually discontinue the client from taking medication (Bayliss, & Holttum, 2015). CBT as an adjunct to medication is more effective than medication alone because it will augment CBT impacting

the distorted thoughts, inability to concentrate and fatigue (Bayliss, & Holttum, 2015). The impact of CBT also helped the client identify the source of anxiety and identified goals to control emotion and improve communication boundary setting. 

Progress and lack of progress toward the set-up goals:

IA was consistent in attending therapy and understood the focus of the treatment. IA consistency helped her to stay focused, and work (progress) towards her set goals. The CBT helped to reverse her distorted and maladaptive beliefs to embracing better positive ways of thinking and reasoning. CBT focuses on the challenges and changes unhealthy, harmful behavior, leading to improved emotional stability and developing strategies in resolving problems (Mehta, 2018). IA reports stable emotion, less anxiety, healthy boundaries, and positive ways of communication.

Modification(s) of the treatment plan that was made based on progress/lack of progress

IA is progressing well in the current treatment plan, CBT, and medications. No modifications to the treatment plan are currently necessary. Additional antianxiety medication was started to ensure zero anxiety and depression level. 

Clinical impressions regarding diagnosis and or symptoms

The clinical impression enables the practitioner to arrive at a diagnosis after assessing the client to determine the problem patient has (Snow, 2020). The nurse practitioner will communicate to the patient the assessment, and the diagnosis; the relevant interventions are because of the outcome of the precise information provided. Snow (2020), stresses the need to empower patients and family to be actively involved in identifying priorities and developing working strategies that are realistic in achieving positive outcomes. IA was able to set both short- and long-term goals as relates to treatment therapy. 

Relevant psychosocial information or changes from original

assessment (e.g., marriage, separation/divorce, new relationships, move to a

new house/apartment, change of job)

The client has more confident about setting boundaries and in improving communication between mom and her boyfriend. IA reports she knows the direction she wants the relationship to go. IA reports interest in school and that one day, she hopes to graduate to become a neurologist. 

Safety issues: IA reports no safety concerns. IA reports consistency in taking her medications as well as attending therapy sessions as scheduled. 

Clinical emergencies/actions taken: No clinical emergencies reported. 

Medications used by the patient: Zoloft 25 mg PO daily. Vistaril 50 mg 1 capsule orally, TID PRN. Trazodone 50 mg 1 tab orally, at nighttime PRN.

Treatment compliance/lack of compliance: IA is consistent in taking medications as prescribed.

Clinical consultations: There was no clinical consultations currently necessary since IA is responding positively with medications and CBT. 

Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists): IA’s mom calls the psychiatrist for medication refills seven days before running out. IA is compliant with the treatment plan. No other collaboration currently. 

The therapist’s recommendations: The therapist recommends continuing process groups to facilitate ongoing progress towards treatment and therapy. IA’s mom did not object to the plan. 

Referrals made/reasons for making referrals: The therapist will determine the need for referral towards the completion of therapy. Currently, no referrals made yet. 

Termination/issues that are relevant to the termination

process (e.g., the client informed of the loss of insurance or refusal of the

insurance company to pay for continued sessions): IA is on mom’s

insurance, therefore, continues therapy sessions as scheduled. No insurance issues. 

Issues related to consent and informed consent for treatment: Consent was obtained from IA’s mom before initiation of therapy and antidepressant. No current consent issues. 

Information concerning child abuse and elder or dependent adult abuse, including documentation as to where the abuse was reported: None reported. 

Information reflecting the therapist’s exercise of clinical judgment: The treatment modalities in IA’s treatment plan has positive therapeutic effect in achieving a balance between distorted thoughts and maladaptation versus developing healthy boundaries and positive coping strategies in handling negative thoughts. IA was also consistent in taking her medications and attending therapy with positive outcomes. Experience, knowledge, practice, and critical analysis helps practitioners in developing clinical judgment and are incorporate in our diagnosis, treatment plan, communication, decision-making and our everyday practice (Kienle and Kiene, 2010). 

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Assignment.

Title:  Client attempted suicide by overdosing

Session: Process group

Date: 07/12/20       Time: 1000-1100

Present: IA

Subjective statement: IA states, “I don’t feel loved. I am always judged both at home and

school.” 

Objective data: IA suffers from a generalized anxiety disorder that is recurrent and severe and does not present with psychotic features. IA report suicidal ideation by overdosing on medication. IA reports symptoms of decreased sleep, decreased appetite, increased anxiety, seclusion in her bedroom, periodic crying spells, and loss of interest in school and social activities. She started street drugs and attempted suicide by overdosing on medication. IA was alert and oriented x 4, well-groomed, with appropriate affect. Speech is well articulated. IA responds to questions appropriately and willingly. IA has a cheerful disposition, cooperatives, and interacts well with the therapist and other peers. IA has an honest insight into the

situation, unhappy due to constant conflicts with mom and boyfriend. Rates

anxiety and depression 10/10. IA denies current suicidal ideation. 

Assessment: To assess IA for potentially lethal suicide attempts. 

Plan: Outpatient referral, therapy initiation to help in symptom reduction. IA and mom were given emergency/crisis numbers. Treatment plans include medication in combination with psychotherapy. Consultation and referral to be determined by the therapist if needed. The patient is admitted for counseling with antidepressants and CBT; Progress is reassessed after two weeks of initiating therapy sessions. 

Explain why the items you included in the privileged note would not be included in the client's family’s progress note. 

The psychotherapist takes privileged notes that are not included in the progress notes to allow the therapist to communicate confidentially without obligation to disclosure by third parties example insurance claim and legal proceedings (Mills, 2015). Privilege notes promote client/therapist relationship in that it contains statements clients made in confidence to the therapists that do not trigger safety concerns or observations made by the therapists during process group that helps the therapist remember essential discussions with the client. Privilege notes are kept separate from other psychotherapy notes and are not part of client’s medical records. It is important to note that the privileged notes help the therapist protect the client as opposed to the therapist (Corey, Corey, & Callahan 2011). Breaking client’s confidentiality can have a devastating effect on the client; therefore, it should be handled carefully (Lasky and Riva, 2006). 

Explain whether your preceptor uses privileged notes.

My preceptor uses privileged notes inform SOAP note. The SOAP notes contain sensitive concerns various clients stated and objective information and assessment the therapist gathered during therapy sessions about each patient separately. My preceptor has peculiar separate ways to identify each client without violating trust and confidentiality purposes. He does not use patient’s actual names to avoid HIPAA violations.

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