Diagnostic and Statistical Manual of Mental Disorders
Progress notes enhance care delivery in medical facilities. Healthcare practitioners use progress notes to document the medical record of their patients. The notes enable providers to monitor the patient’s clinical status throughout outpatient care or hospitalization. Therefore, progress notes guide clinicians in deciding the next course of action when providing care to a particular client. On the other hand, the privilege note indicates that the client has a right to stop the psychologist from disclosing confidential information to unauthorized parties (Wheeler et al., 2014). The progress and privilege notes will focus on the client’s family, M.S., treated in the Week 3 Practicum Assignment.Diagnostic and Statistical Manual of Mental Disorders
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Treatment Modality
Group therapy is the treatment modality that was utilized with the client, M.S. One or more psychologists guide a group of approximately five to fifteen clients in this type of therapy. A group meeting is scheduled for one or two hours weekly. Most groups target a particular problem, including depression, bipolar, substance use disorder, and obesity. Additionally, the group aim at helping the members cope with symptoms of a specific condition such as anger, anxiety, loss of interest in activities, and low self-esteem. This treatment modality was useful in solving the patient’s problem. The client benefited from the support network provided by other members. Additionally, the patient gathered the courage to deal with her problem upon learning that she was not alone, but others struggled with a similar situation.
Progress Towards Client Goals
Progress toward the mutually agreed-upon client goals was reported. According to the treatment plan, the modality was supposed to reduce the severity of various symptoms associated with this condition. First, the plan indicated that the treatment would reduce the abrupt moods change. This goal was achieved since the client’s mood stopped changing abruptly. Secondly, the therapy managed a loss of interest in activities as proposed in the treatment plan. Therefore, the treatment modality was facilitating progress towards client goals.
Modification of the Treatment Plan
The progress indicates that the treatment plan requires some modifications. Progress towards client goals was beyond the expectations. Therefore, the treatment period should be reduced since the desired results seem achievable within a relatively shorter duration. Diagnostic and Statistical Manual of Mental Disorders
Clinical impressions regarding diagnosis and or symptoms
Relevant Psychosocial Information
The client was negatively affected by the health condition. Therefore, some changes from the original assessment were reported. The changes were associated with disruption in her functional, occupational, and social activities.
Safety Issues
The client’s condition was associated with some safety issues. The client had to take much more alcohol than usual to sleep when she was full of energy. Excessive consumption of alcohol increased the risk of harming herself. Specifically, the client would harm herself if she experienced abrupt moods change, making it challenging to control her emotions. Additionally, the client could harm her children if abrupt moods change occurred while she was drunk.
Clinical Treatment
No clinical emergencies that were reported for this client. Consequently, the client did not use any medications. Additionally, no treatment compliance and clinical consultations were reported.
Collaboration with other Professionals
The treatment of this client was enhanced by collaborating with other professionals. First, the therapist made phone consultations with physicians. The provided information was used to facilitate the management of the presented symptoms. Additionally, the psychologist contacted a psychiatrist during the therapeutic period and shared the presented symptoms. The psychiatrist ruled out that the client did not have any mental condition. The presented symptoms were not associated with mental conditions (American Psychiatric Association, 2013). Consequently, the therapist diagnosed the client with a cyclothymic disorder based on the DSM-5 criteria. According to Van Meter et al. (2017), the cyclothymic disorder is characterized by various symptoms, including abrupt mood changes. Additionally, the disorder is associated with fatigue and loss of interest in activities (American Psychiatric Association, 2013).
The therapist’s Recommendations
The client agreed to the therapist’s recommendations. The client adhered to the proposed measures, including attending all weekly therapeutic sessions, contributing during group discussions, and asking if she required clarification. This action facilitated the management of the presented symptoms since the client could learn from other group members during the therapeutic sessions. However, no referral was made since the therapist could handle the client’s situation comfortably, making it unnecessary to seek assistance from other professionals. The client continued with therapeutic sessions to the end of the treatment period without termination.Diagnostic and Statistical Manual of Mental Disorders
Informed Consent for Treatment
The therapist obtained informed consent from the client at the beginning of the therapeutic sessions. Informed consent is one of the primary ethical principles that therapists should adhere to while counseling their clients. This ethical principle states that a psychologist should inform the client before starting the therapy (American Psychological Association, 2017). Similarly, the client was briefed about the treatment, including the length, participants, and expectations during various sessions. The therapist then left the client to decide whether to participate in the therapy without coercing her.
Reflection of the Therapist’s Exercise of Clinical Judgment
The health outcomes indicate that the therapist managed the presented condition effectively. The applied group therapy reduced the severity of the symptoms of cyclothymic disorder significantly. The effective treatment facilitated the achievement of the client’s goals within a shorter period than expected.
Part 2: Privileged Note
Items that are not documented in the note as a clinical record
The client denies any medical history of mental illness in her family. However, a mental condition can be deducted through her tendency to consume excess alcohol to sleep when experiencing full energy. The likelihood of a mental condition was increased by her paternal grandmother being diagnosed with Alzheimer’s disease. Therefore, the patient is likely to have developed the cyclothymic disorder. Collaborating with the treatment plan effectively would help the client to manage the symptoms of this psychological condition.
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Reasons for these items would not be documented in the progress note.
The items included in the privileged note would not be documented in the progressive client note since they had information about the client’s excessive alcohol consumption and the history of Alzheimer’s disease in her family. These items do not reflect the client’s current progress.
Does my Preceptor utilize Privileged Notes?
My preceptor utilizes privileged notes. Specifically, the hypothesis on the diagnose and observations. Additionally, the emotions about the medical conditions of the client are used. Professionals should ensure that the privileged notes are kept away from the client’s medical records and billing information. Nonetheless, observations of the providers, hypothesis, and preceptors’ questions should be included (Mills, 2015).Diagnostic and Statistical Manual of Mental Disorders
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.
American Psychological Association (2017). Ethical Principles of Psychologists and Code of Conduct. http://www.apa.org/ethics/code/ethics-code-2017.pdf
Mills, J. (2015). Psychotherapist-Patient Privilege, Recordkeeping, and Maintaining Psychotherapy Case Notes in Professional Practice: The Need for Ethical and Policy Reform. Canadian Journal of Counselling and Psychotherapy, 49(1).
Van Meter, A. R., Youngstrom, E. A., Birmaher, B., Fristad, M. A., Horwitz, S. M., Frazier, T. W., … & Findling, R. L. (2017). Longitudinal course and characteristics of cyclothymic disorder in youth. Journal of affective disorders, 215, 314-322.Diagnostic and Statistical Manual of Mental Disorders