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Walden University Client Progress And Privileged Notes

Walden University Client Progress And Privileged Notes

Question Description

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

  • Treatment modality used and efficacy of approach
  • Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—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 (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
  • 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 (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
  • 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 (i.e., 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 from the Week 3 Practicum Assignment.

  • The privileged note should 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’s progress note.
  • Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

The client is 40 years old caucasian single male; he lives in a group home with a history of a substance use disorder, anxiety disorder, posttraumatic stress disorder. He presented with feeling depressed, sad, and having anxiety and flashbacks about his brother, who was killed by a police officer and when a correctional guard choked him. Also, the client reported that the recent unrest in the metro area had triggered an old memory. He stated that he has been using marijuana, cocaine, and alcohol daily. The client reported that he has not been taking his medications. Additionally, the client reported that he is seeking treatment and wants to maintain his sobriety.

Past psychiatric history: Depression, Posttraumatic Distress Disorder, Anxiety Disorder, Substance use Disoder

Medical history: Diabetes and Hypertension

Medications: Lisinopril, Vistaril, Metformin, Prozac

Substance use history: Marijuana, Cocaine and Alcohol

Developmental history: client appears to look stated age. Denied any developmental delays

Family psychiatric history:

Paternal Grandfather: Depression

Paternal Grandmother: Unknown

Maternal Grandmother: None

Maternal Grandfather: Marijuana user

Mother: Depression and SUD

Father: Cocaine user

Brother: SUD

Psychosocial history: Client is single. No kids. Client states he lives in a group home. He goes for a day program daily. Client wants to go back to school. He has one year of college experience.

History of abuse/trauma: Client stated he was neglected by his parents. He reported physical and verbal abuse by his parents when he was much younger

Mental status exam:

Orientation: Alert and oriented to person, place, time and situation.

Appearance: Appropriately dressed

Musculoskeletal: gait and

Behavioral: Calm and cooperative

Motor activity: Appropriate

Speech: normal rate and volume

Mood: depressed

Affect: Sad

Thought process: Logical and goal oriented

Thought content: Denied suicidal ideation and homicidal ideation

Perception: Denies hallucinations and delusions

Attention and concentration: Intact

Remote and recent memory: Client was able to remember recent and past events dates

Insight and judgment: Intact. Goal oriented

Differential diagnosis:

Major Depression Diorder:

(major depressive disorder) is a common and serious medical illness that negatively affects how you feel the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home. MDD represents the classic condition which is characterized by five or more symptoms that have been present during the same 2-week represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure (DMS-5)

Substance Use Disorder

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems (DMS-5). Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed. As a general estimate of severity, a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Changing severity across time is also reflected by reductions or increases in the frequency and/or dose of substance use, as assessed by an individual’s own report, report of knowledgeable others, clinician’s observations, and biological testing (DMS-5).

Anxiety Disorder

Generalized anxiety disorder, or GAD as it is more commonly referred to, is an anxiety disorder characterized by excessive worry or apprehension displayed across a variety of everyday situations or activities. Patients with GAD worry about things that most people will from time to time worry about, such as health, finances, work difficulties, or family problems (Bystritsky, Khalsa, Cameron, & Schiffman, 2013).

Posttraumatic Stress Disorder

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation of PTSD varies. In some individuals, fear-based re-experiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most distressing. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns (DMS-5).

Case formulation:

The client reported that he has been using marijuana, cocaine, and alcohol since age eight. The client reported that his parents were not around most of the time. He experienced some form of neglect. The client reported that he was abused as a kid by his parents physically and verbally; a correctional guard in jail choked him, and a police officer killed his brother. He usually has flashbacks about these incidents. He has been feeling depressed regarding the death of his brother and the recent unrest in the metro area. He reported that he has been dealing with depression and anxiety since age ten but that it has worsened two years ago after he lost his brother. Sometimes he gets anxious. He stated that he has been more depressed since the unrest in the metro areas. He stated, “it triggers a lot of things.” The client reported that he has been using substances daily to escape his problems. The client has been in treatment multiple times.

Additionally, the client reported that he has hypertension and diabetes. The client is seeking treatment; he reported that he has not been taking medications. Also, he reported that was prescribed Prozac, Lisinopril, Metformin and Vistaril.

Treatment plan:

Safety plan: Client is not deemed as an imminent risk to self or others. The client will be educated to tell staff if safety issues arise. He is motivated about treatment, planning to maintain his sobriety and is willing to restart his medications.


Goal: to minimize depressive symptoms such as being sad and lack of energy to do things.

Treatment plan: to use psychotherapy such as CBT in conjunction with antidepressants.


Goal: For the client to have minimal to no flashbacks of the traumatic event from 2018.

Treatment plan: The client will continue to see psychiatrist and counselor to learn and develop coping skills that will help the client manage symptoms.

Substance use disorder

Goal: client will to stop using drugs and figure out how not to relapse anymore

Plan: Client will see counselor twice a week to learn healthy coping skills and apply it

Anxiety disorder

Goal: will reduce overall level, frequency, and intensity of anxiety so that daily functioning is not impaired.

Treatment plan: will teach and support the client to learn and be able to verbalize at least 2 communication strategies that can help decrease anxiety to the point where anxiety will occur less than once per day.


Medication for depression, anxiety, diabetes and hypertension risks, benefits, significant/common side effects, and alternatives of below medication plan with the client who verbalized understanding and agreed with the idea. The writer educated the client on the importance of abstaining from ETOH, marijuana, and cocaine. Educated clients if experiencing sedation from medications, the client should not operate heavy machinery or drive and report side effects. The client will continue to attend group and individual sessions.

According to Dunlop, Scheinberg & Dunlop 2019, just as there are specific medications, there are particular forms of psychotherapy. In particular, patients with anxiety disorders benefit from cognitive behavioral therapy (CBT), in which they undergo exposure to their fears and gain mastery over them. There are several forms of effective psychotherapy for depression, including CBT and interpersonal therapy. Non-specific ‘supportive’ therapy can help people in times of crisis or stress but is typically not efficacious for severe mental health disorders. Family therapy or behavioral marital therapy can be effective when dysfunction in families or couples is a primary driver of the patient’s depressive symptoms. Providers should be aware of local therapists who practice evidence-based forms of treatment.

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