Description/Paper Instructions: Comprehensive Client Family Assessment and Genogram
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
· 1-Treatment modality used and efficacy of approach
· 2-Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
· 3-Modification(s) of the treatment plan that were made based on progress/lack of progress
· 4-Clinical impressions regarding diagnosis and/or symptoms
· 5-Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
· 6-Safety issues
· 7-Clinical emergencies/actions taken
· 8-Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
· 9-Treatment compliance/lack of compliance
· 10-Clinical consultations
· 11-Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
Comprehensive Client Family Assessment and Genogram
· 12-Therapist’s recommendations, including whether the client agreed to the recommendations
· 13-Referrals made/reasons for making referrals
· 14-Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
· 15-Issues related to consent and/or informed consent for treatment
· 16-Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
· 17-Information reflecting the therapist’s exercise of clinical judgment
Note: Be sure to exclude any information that should not be found in a discoverable progress note.
Comprehensive Client Family Assessment and Genogram
Comprehensive Assessment
- Demographic information: The patient is a 17-year-old black girl. She is escorted by her parents to the clinic after a recommendation from the school counsellor.
- Presenting problem: According to the father, “our daughter is not feeling well. She has not been attending classes and she tried to commit suicide. We think she is depressed”.
- History of present illness: On today visit, patient present awake, alert and oriented, calm, cooperative, organized, with good hygiene. According to the young girl who was ready to share her feelings, she started feeling pressure from schoolwork when she was in her junior year. Her grades were not so good, and she felt useless and that is why she started being a truant. One year later, after starting her senior year, she feels the pressure is too much and she cannot manage to go through the year. One day before being referred to the clinic by the school counsellor, she was found bleeding in the school washroom after she slit her wrist.
- Past psychiatric history: Since her frustration with school started a year ago, she has never been diagnosed with any psychiatric disorder. The parents though that she was simply going through a phase as a teenager and they were trying to help her cope with school and be a better person. No past psychiatric history. No history of Abuse.
- Medical history: Despite her recent issue and the fact that she lost her weight suddenly, in the past few months, she is of perfect health. she had asthma and chicken pox when she was young, and she is allergic to penicillin.
- Substance use history: She has no history of substance abuse. Her parents describe her as a very good girl.
- Developmental history: Her mother had a successful pregnancy and gave birth to her through normal delivery. She grew up with her older siblings and she achieved all developmental milestones. They have been going to church every Sunday and she is part of the local church youths. Her parents have been married for a while and they are still together. She went through her education as a bright girl until her junior high level when she started failing and missing classes.
- Family psychiatric history: Her older sister has epilepsy, but her seizures remain under control. There is no other form of psychiatric history in the family
- Psychosocial history: She has always been an active member of the church youth and they have been doing many activities together since they were in Sunday school. She has also been making many friends from high school but recently, she just wants to be alone
Comprehensive Client Family Assessment and Genogram
- History of abuse and trauma: There is no history of abuse or trauma. The parents say that they love and take good care of their daughter and provide everything she wants.
- Review of systems: She states that she has been feeling sad and irritable all the time. She has not been eating well because of lack of appetite and she finds trouble getting and sustaining sleep. She feels like her life makes no sense because she has been doing very bad in school and she feels bad about it. She denied any heart palpitation, anxiety, sweating or panic attacks. However, she says that she always felt the sense of doom and that is why she went ahead and slit her wrist. HEENT: normal, Respiratory/Chest/Lungs: CTA AP&L: no respiratory problems, no SOB; Breast: Normal, GI: Normal, GU: Normal, Neuro: AAOx3, Endocrine: Normal; Genital/Rectal: Normal condition,
- Physical assessment: Head and neck are normal. Chest and abdominal examination are normal. No headache, no dizzy, are normal and musculoskeletal examination is normal.
- Mental status exam: She appears normal and well dressed for the weather. She readily shares her feelings and her shoulders are constantly sagging. She avoids eye contact and expresses guilt for her actions. She has logical judgement and understands the need not to cause harm to herself and the implications to her family. Her perception is normal, and her speech is shaky and traumatized. There are no movement abnormalities.
- Differential diagnosis: Major depressive disorder, Bipolar disorder, Anxiety disorder
- Case formulation: The client is a young teenage girl of African American origin. She is 17-year-old and experiencing sadness, worthlessness, hopelessness, fatigue, depressed mood, lack of interest in education and life and she has unsuccessfully attempted suicide. These are symptoms that meet the criteria for diagnosing MDD (American Psychiatric Association, 2013). The stressor for this client is her studies and pressure from family to achieve. In American adolescents, studies have shown that they deal with depression in different ways including aggressive behavior to others and having others reach out (Al-Khattab, Oruche, Perkins & Draucker, 2016). In this case, the client might have attempted suicide for many reasons including as a cry for help. There is need to include the parents in helping her cope with the situation at school. Being an adolescent and a woman might have also increased her susceptibility especially when social support was not enough when she needed it as scholars have established in a research (Van Droogenbroeck, Spruyt & Keppens, 2018).
- Treatment plan: The client should be started on a cognitive therapy first in order to change her thought process and pattern with a view of promoting positive thinking and changing her behavioral pattern as well (Chand & Arif, 2019). In the case that antidepressants are considered necessary, the parents shall be consulted, and they shall be informed about the risks and benefits of using them before they give consent to any pharmacological treatment. However, CBT should be effective with the support from family and teachers at school.
References
Al-Khattab, H., Oruche, U., Perkins, D., & Draucker, C. (2016). How African American adolescents manage depression: Being with others. Journal of the American Psychiatric Nurses Association, 22(5), 387-400
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub
Van Droogenbroeck, F., Spruyt, B., & Keppens, G. (2018). Gender differences in mental health problems among adolescents and the role of social support: results from the Belgian health interview surveys 2008 and 2013. BMC psychiatry, 18(1), 6.
Chand, S., & Arif, H. (2019). Depression. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430847/
Comprehensive Client Family Assessment and Genogram
|
RUBRIC
Quality of Response |
No Response |
Poor/Unsatisfactory |
Satisfactory |
Good |
Excellent |
Content (worth a maximum of 50% of the total points) |
Zero points: Student failed to submit the final paper. |
20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. |
30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. |
40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. |
50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. |
Use of Sources (worth a maximum of 20% of the total points). |
Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. |
5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. |
10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. |
15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. |
20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. |
Grammar (worth maximum of 20% of total points) |
Zero points: Student failed to submit the final paper. |
5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors |
10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors |
15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. |
20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. |
Structure of the Paper (worth 10% of total points) |
Zero points: Student failed to submit the final paper. |
3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. |
5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. The can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper |
7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. |
10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. |
|
|