Journal Entry

art 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.

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.

RUNNINGHEAD: PROGRESS NOTE

1

Lisa Bell

Progress Note

Week 7

NURS 6650- Practicum

Walden University

October 2019

PROGRESS NOTE 2

Progress Note

Part 1

The purpose of this paper is to write progress note and a privileged psychotherapy note

regarding the family assessed in a prior comprehensive assessment.

Clients: ​A.W., 31 year old Caucasion female, P.G. 47 year old Latino male.

Diagnosis (DSM-5):​ Relationship distress with an intimate partner, Generalized Anxiety

Disorder (GAD) (American Psychiatric Association, 2013).

The clients present with relationship difficulty due to their personal mental health issues,

history of negative relationships, and wishes to learn hope to manage conflicts and evaluate the

future of their relationship.

Treatment modality used and efficacy of approach: ​Family therapy session with a Cognitive

Behavioral Therapy approach, progress thus far has been minimal, with realistic expectations

identified, and one temporary breakup in their relationship.

Progress and/or lack of progress toward the mutually agreed-upon client goals:

The client goals were to evaluate if their relationship was worth saving or if it was

mentally and physically exhausting to be in a partnership. They desired to have a healthy

relationship with each other and be a strong example for their small formattable children. Stress

of work, school, and social obligations has exacerbated A.W.’s anxiety and manic state of

bipolar disorder, and this has caused disruption in their relationship, and negatively to the point

that P.G. decided to take a break would be the best for a short time.

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

Based on the lack of understanding of psychological turmoil that A.W. is suffering from, their

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treatment plan was modified to enhance their pattern of thought and integrate mindfulness CBT.

Mindfulness CBT teaches how to increase one’s presence in a relationship and the ability to

relate to their partner, as well as decreased associated anxiety, which had impair relationships as

well, and disrupt its balance (Gillihan, 2017).

Clinical impressions regarding diagnosis and or symptoms: ​Increased individual anxiety,

manic episode of bipolar disorder, both impact their relationship and increase overall anxiety.

Inability to effectively cope with unexpected stress and immediately revert to ending the

relationship instead of understanding the thoughts, behaviors, and emotions of the counterpart. .

Relevant psychosocial information or changes from the original assessment: ​ The couple

broke up their relationship for three days after an intense conversation, and inability for P.G. to

cope with A.W.’s anxiety and manic mood. They rekindled their relationship after discussing

their desired to still be together and their love for each other. No other changes occurred from

the original assessment.

Safety issues: ​ No significant safety issues noted.

Clinical emergencies/actions taken: ​No clinical emergencies noted.

Medications: ​ A.W. is prescribed Latuda, Lamitcal, and Propranolol. P.G. is prescribed Plavix,

Coreg, and Prozac

Treatment compliance/lack of compliance: ​ Compliant with medications. Noncompliant to an

extent with mindfulness techniques and CBT therapy modules.

Clinical consultations: ​Individual therapy in addition, with review of medication management

with an PMHNP for both clients, and referral to couple therapy specifically.

PROGRESS NOTE 4

Collaboration with other professionals: ​Referral for a therapy that specializes in couple

therapy, and PMHNP for continuation of medication management.

Therapist’s recommendation: ​Continue family therapy, set up couple therapy and

appointments with PMHNP to adjust or evaluate mediation management and effectiveness. Use

mindfulness techniques such as acknowledging the partners feelings, and writing down thoughts

when anxiety increases or unexpected outcomes occur.

Referrals made/reasons for making referrals: ​Individual sessions for both partners, especially

A.W.

Termination/issues: ​N/A

Issues related to consent and/or informed consent for treatment: ​Patients made aware of

treatment plan, consents to treatment with counselors, coping mechanisms, referral to individual

therapist sessions and PMHNP for further medication management.

Information concerning child abuse and/or elder or dependent adult abuse: ​Client’s

informed of negative impact on young children to be involved a unstable relationship, with high

anxiety and history of domestic violence. Informed client’s that any confidential information

regarding the impaired safety of a child or elder will be reported.

Information reflecting the therapist’s exercise of clinical judgment: ​Clinical judgement of

these clients is that there is a lack of relationship support for the two of them to learn from or

seek for healthy boundaries. Both of them had divorced parents and have had several failed prior

relationships, therefore developing a healthy supportive and strong relationship is difficult.

When A.W.’s anxiety or mood disorder changes, she must work on her coping mechanisms and

controlling her emotions and anxiety, and P.G. must work on accepting her psychological

PROGRESS NOTE 5

rollercoaster, and learn coping skills and acknowledge alternative outlets, if they both wish to

pursue a healthy relationship.

Part 2

Privileged Note

This couple is seeking either confirmation that their relationship is not meant to be or

hope through therapy that it will actually work out. However, with their past record of both

having unsuccessful relationships, and having broken up multiple times over the past two years,

despite their effort, they will be their own demise. They both must old accountability for their

own actions and listen to one another in order to formulate a healthy relationship and be a good

example for the children in their lives. It is difficult to communicate with someone that is not

willing to listen or change, or be mindful other how their actions affect the other person. It

seems as if P.G. does not want to entertain the stress of A.W.’s mental disorders, and is easily

disengaged when her emotions and anxiety are high. A.W.’s if putting forth more effort into

making the relationship “work” and this can get exhausting if she continues despite the true

intentions or desires of P.G.

Privileged notes or psychotherapy notes are additional notes that are not part of

required medical record and do not contain medical information or identifying information. The

laws of HIPAA allow these notes to disclose the “therapist’s personal notes, such as thoughts and

feelings about a case, theoretical analysis of sessions, or notes in preparation for consultation”

(Griswold, 2017). Privileged notes are still confidential legally and must be securely kept, but

are not a required aspect of therapy evaluation. One would not include personal thoughts or

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feelings, hunches or hypotheses into a progress note. As well privileged notes can be a reminder

of a session, a self-consultation without detailed information or violating HIPAA.

The preceptor that I am currently with does not use privileged notes, only progress notes

that are shared within the medical record of each client. Progress notes are used for

collaboration and continuation of therapy to enhance the client’s care. Progress notes are already

time consuming and additional privileged notes are not necessary to fulfill the requirements,

especially since so many groups rotate through the practice.

PROGRESS NOTE 7

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.

Gillihan, S. (2017). 8 ways CBT can improve your relationship. ​Psychology Today

March 2017. Retrieved from

https://www.psychologytoday.com/us/blog/think-act-be/201703/8-ways-cbt-can-improve

-your-relationship

Griswold, B. (2017). Progress notes vs. psychotherapy notes: Do you know the

difference? Retrieved from

https://navigatingtheinsurancemaze.com/articles/progress-psychotherapy/