Practicum – Assessing Client Family Progress
Learning Objectives
Students will:
· Create progress notes
· Create privileged notes
· Justify the inclusion or exclusion of information in progress and privileged notes (SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE)
· Evaluate preceptor notes
To prepare:
· Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),
The Assignment
Part 1: Progress Note
Using the client family from your Week 3 Practicum Assignment 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. (SEE ATTACHED WEEK 3 NOTE),
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.
HERNANDEZ FAMILY CASE STUDY 2
Part 1: Comprehensive Client Family Assessment
Demographic information
Juan Hernandez Senior is a 27-year-old Latino man who is married to a 25-year-old Latino woman, Elena Hernandez and both have a family (Hernandez family).
Presenting problem
Junior Hernandez Senior described that his parents used to punish him while he was a kid and that he ended inheriting the behavior of punishment his children from his parents. The punishment was so painful to him since he would be made to hold the heavy books form encyclopedia. Juan Hernandez Senior explains that he inherited this behavior of disciplining his children from his parents. The social work has been sent to Juan Hernandez Senior since the children are complaining of how painful this punishment has been to them, especially to Juan Hernandez Senior.
History of present illness
The father of Juan Hernandez senior, Hector reports that Hernandez has not drug abuse problem though he has had criminal history of petty theft.
Past psychiatric
The father reports that Hernandez senior has been of sound psychiatric health status.
HERNANDEZ FAMILY CASE STUDY 3
Medical history
The father reports that Hernandez senior has been okay health-wise. However, her wife, Elena Hernandez, has recently been diagnosed with diabetes.
Substance use history
No history of substance abuse has been reported for the parents of Hernandez senior.
Development history
The father reports that Hernandez senior experienced no delays in development.
Family psychiatric history
No psychiatric issues in the family history of Hernandez senior’s parents
Psychosocial history
Hernandez Senior is described as a sociable person who was able to interact in friendly manner with his parents and friends.
History of abuse/trauma
No other form of abuse has been reported on Hernandez senior apart from the punishment of holding heavy books that his parents used to institute on him. As such, he did not inherit any other form of punishment from his parents.
HERNANDEZ FAMILY CASE STUDY 4
Review of Systems:
Physical assessment
Juan Hernandez Senior is medium-slim Latino male who seems to be cheerful and smart all the time.
Mental status exam
The counseling has to involve the whole family: Hernandez senior, Elena Hernandez, Hernandez Junior, and Alberto Hernandez. This is because there is need to address all the root causes of the current problem (Wheeler, 2014). Hernandez Senior seems to be a bit ready to learn how he can overcome the habit that he inherited from his parents of giving his children torturing punishment of holding heavy encyclopedia books. This is because he does not see why his children should suffer the same way he used to suffer while undergoing the same punishment. He is, therefore, ready to be helped how he and his wife can stop this habit and improve their relationship with their children.
Differential diagnosis
Both Hernandez Senior and his wife, Elena Hernandez married at very young age and inherited many behaviors from their parents, including the way to raise and discipline children.
HERNANDEZ FAMILY CASE STUDY 5
Diagnosis
The diagnosis is to do with how Hernandez senior and his wife can change their behavior which they inherited from their parents on how to discipline their children.
Case formation
A social worker will try to assess why Hernandez senior inherited the behavior of disciplining his children from his parents and how this behavior can be stopped. Hernandez Senior is a casual worker at the airport and sometimes drinks 6-8 beer on weekends. He has had petty criminal record while at tender age. His wife has had no criminal or drug abuse record.
Treatment Goals
Goals: The goals for treatment is to help Hernandez Senior to do away with the behavior he adapted from his parent of punishing his children the way he does and also adapt new positive ways of disciplining them in the way that will improve the relationship with his children.
Treatment strategy/interventions: The first treatment strategy or intervention will involve removing the anger that Hernandez Senior underwent through when enduring the harsh punishment from his parents. The other treatment strategy will involve teaching Hernandez senior and his wife, Elena Hernandez, the positive and safe skills which are effective in disciplining their children. This will improve the parent-child relationship.
Estimated completion: 3 months
HERNANDEZ FAMILY CASE STUDY 6
Part 2: Family Genogram
Juan Hernandez
HERNANDEZ FAMILY CASE STUDY 7
References
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
