The info can be made up. I have attached 2 sample papers. The attachment that states progress note is the one I used for the week 3 assignment. The other paper is a sample paper another student did I found on the internet.
Part 1: Progress Note
Using the client family from your Week 3 Practicum Assignment-see progress note attachment, address in a progress note (without violating HIPAA regulations) the following:
•Treatment modality used and efficacy of approach
•Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)
•Modification(s) of the treatment plan that were made based on progress/lack of progress
•Clinical impressions regarding diagnosis and or symptoms
•Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
•Clinical emergencies/actions taken
•Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
•Treatment compliance/lack of compliance
•Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
•The therapist’s recommendations, including whether the client agreed to the recommendations
•Referrals made/reasons for making referrals
•Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
•Issues related to consent and/or informed consent for treatment
•Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
•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.
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.
In your progress note, address the following:
•Include items that you would not typically include in a note as part of the clinical record.
•Explain why the items you included in the privileged note would not be included in the client family’s progress note.
•Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
Comprehensive Client Family Assessment and Genogram
Part 1: Comprehensive Client Family Assessment
Patient Initials: JS
Age: 35 years
Race: Black American
Family: Married, father to two daughters, one brother, one sister, father alive, mother deceased.
Other Family Members in Attendance:
Patient Initials: LS-wife to JS Age: 40yo Gender: BF
Patient Initials: MS-father to JS Age: 60yo Gender: BM
JS arrived to his counseling appointment accompanied by his wife, LS 40yrs BF and Father MS 60y/o BM. Appointment is for family therapy due to conflict within the family. JS is A&O x4, well groomed, denies any SI/HI/AVH/drugs/ETOH: Reports feeling down and stressed. Not sleeping well, 5-6hrs per day , poor appetite. JS states “I think my father doesn’t care about my health. He wants me to pay him money I don’t have and it’s stressing me out.” JS currently lives in the family home with his wife and kids. Although the home is paid for, His father wants him to pay rent for currently living at the house. MS states he is aware that the situation is stressing JS out, because he has threatened to have him put out. MS feels that JS is taking advantage of him by living for free and he is not allowing that to happen.
History or present illness
LS reports that her husband condition has been worsening for the last three months. According to LS, JS wants to be alone most of the time. Before the onset of the present condition, JS was an excellent family man who loved and cared for everyone. After earning his undergraduate degree ten years ago, JS joined military. The father retired one year later and demanded financial support from JS for supplemental income for staying in the family home. In the first two years, JS gave 30% of his salary to the father and everything worked well. In the third year, JS got married and fathered two daughters. Due to increased family responsibility, he stopped giving the father 30% of his salary. JS has had frequent conflicts with his wife since he could no longer pay the rent.
Past psychiatric history No past psych hx or psych admissions. JS has been currently struggling with depression. An evaluation of family history indicates his father, brother, and sister suffered from depression. The mother died from emphysema in 2004 at the age of 69 while struggling with depression and high blood pressure. JS current prescriptions of fluoxetine 40 mg and venlafaxine 37.5 mg.
The medical history covered the following areas:
Past Diagnosis: JS was diagnosed with high blood pressure three years ago.
Significant family history: The mother died from emphysema. At the time of death, the mother was struggling with depression and high blood pressure. Likewise, the father, brother and sister suffer depression. Lastly, the father is diabetic.
JS is socially withdrawn because he has very few people he can trust. Nevertheless, he spends his free time watching football in a local restaurant. At the same time, JS occasionally attend church activities for spiritual nourishment. He interacts and shares with his brother during occasional visits. He is inactive of military job
History of abuse and/or trauma
JS denied use of alcohol but reported to be a frequent smoker. He smokes three packets of cigarettes on daily basis. However no incident of trauma was noted.
Review of systems
The review of systems covered the following areas in the case study:
General: JS is well groomed. The wife and father is well composed and respond to the assessment questions appropriately.
HEENT: HEENT assessment was not done but no abnormalities were observed on the head, eyes, ears, nose, and throat. Communication with JS was effective.
Neck: JS did not have any issues on the neck. It had a full scope of movement.
Breasts: Not applicable
Respiratory: JS did not report breathing difficulty.
Cardiovascular: Not applicable
Gastrointestinal: Not applicable
Genitourinary: Not applicable
Musculoskeletal: Not applicable
Psychiatric: No SI/HI/AVH.
Neurological: Not applicable.
Integumentary/Hematologic/Lymphatic: Not applicable
Endocrine: Lost 5 lbs in the last 3 months
Allergic/Immunologic: Denies any allergies to medications or foods.
Vital signs: Temperature: 97.8°F, Blood pressure: 129/90 mm Hg, Pulse rate: 80 beat per minute and breathing: 15 breaths per minute.
General: JS is physically alert and oriented x 4,communicative, well groomed
Limited assessment was done on the head, eyes, ears, nose and throat. During assessment, no abnormalities were observed in terms of texture and distribution of air, eye movement, hearing sensations, noise sensation and throat tonsils.
Neck: No abnormities were observed during neck assessment.
Chest/Lungs: The patient had a regular rate of breathing and rhythm.
Neurological: Limited assessment was done. JS was conscious to external environment.
Skin/Lymph Nodes: The skin had no rashes or lesions were noted.
Mental status exam
Appearance: JS was dressed appropriately for the weather
Attitude and Behavior: JS seemed sad. Body language indicated signs of a sorrow mood.
Speech: JS spoke with a lot of bitterness though he was coherent and clear.
Motor Activity: The patient had an upright posture. He could stand and walk without difficulty.
Affect and Mood: He had a sad and hopeless mood. Nevertheless, he was receptive to accept any assistance available.
Perception: No hallucinations reported.
Thought Process: JS thinking was logical
Thought Content: logical
Attention/Concentration: Mentally alert.
Memory: Memory was intact.
Insight: JS Receptive to therapy.
Judgment: Could make independent decisions based on the consequences.
Major depression presents as sadness, unhappy, feeling down or frustration that occurs over a long period of time, usually lasting more than 2 weeks, and affects the person normal routine life process.
Bipolar disorder is characterized with alternating periods of depression/mania and normal mood. The patient loses interests in all activities, mood swings, sadness and loss motivation during depression. On the other hand, the patient feels highly motivated and with high energy in times of mania. At times the patient may experience aggression and agitation. The disorder is common to individuals with a family history of depression.
It’s a depression disorder characterized by complete disconnect with reality. Common symptoms include hallucinations and delusions. The cause of this disorder could be environmental factors or a combination of genetic and environmental factors.
JS is extremely emotional and feels rejected. He experiences lonely moments due to conflict with his father. Inactive job status. The frequent sorrow mood and other symptoms he displays through body language and a family history of depression is enough evidence to conclude he suffers from Depression. The clinical goal is to help JS deal with the present realities in his life by helping him develop coping mechanisms.
Behavioral therapy: Avoid solitary life by joining social groups such as friends and sporting activities. Attend counseling classes for eight weeks. The classes will be attended once per week.
Pharmacological care: Prescribe valproic acid 250 mg/day per day for use when the depression is high to help JS stabilize his moods.
Family Therapy: Wife, Father and JS to attend family therapy once a week. Attempt to help JS understand that he has responsibilities, regardless if he is unable to fulfill them or not, help establish a health family relationship by helping the family establish some type of agreement that would work in all favors.
Quality of Response
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.
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