Description/Paper Instructions
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.
The Assignment
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)
•Safety issues
•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
•Clinical consultations
•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
Demographic information
Patient Initials: JS
Age: 35 years
Gender: Male
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
Presenting problem
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.
Medical history
The medical history covered the following areas:
Past Diagnosis: JS was diagnosed with high blood pressure three years ago.
Medications: Chlorthalidone 50 mg, fluoxetine 40 mg and venlafaxine 37.5 mg
Allergies: None
Reproductive history: sexually active, no prostate or reproductive issues reported.
Immunization history: Flu vaccine 2019. Pneumonia Vaccine 2019, PPD-neg.
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.
Psychosocial history
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.
Physical assessment
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
HEENT:
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.
Differential diagnosis
Major Depression
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
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.
Psychotic 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.
Case formulation
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.
Treatment plan
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.
GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER 
