Patient’s Scenario

 

The patient is 59 years old African American male who was admitted to the long term due to declining in health. The patient is alert and verbally responsive. He was admitted with a diagnosis of Mood disorder, depression, and Bipolar disorder. Patient on the following medications: Risperidone 0.5mg 1 tab PO at bedtime. Depakote 250mg 3tabs PO at bedtime. The patient reported that he is feeling great today. The psychiatrist saw the patient in February, and no medication reduction was recommended. The patient was encouraged to not refused his medication and reported any unusual feelings.

Reflect on the client you selected for the Week 3 Practicum Assignment.
Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format.

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