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.)
Clinical emergencies/actions taken