Privileged psychotherapy note example

Assessing Client Progress 4

Assignment 2: Practium- Assessing Client Progress

Name:

Course:

Professor:

School:

City and State:

Date:

Question

Differentiate progress notes from privileged notes

Privileged records is a set of information which involves only two parties, the client and the therapist and this information remains confidential, and even the law does not permit forceful disclosure of the content. On the other hand, a progress note is a medical record where a medical practitioner or psychiatrist records details of a patient, the clinical status and the progress they have made during therapy.

Question

• Reflect on the client you selected for the Practicum Assignment.

• Review the Cameron and Turtle-Song (2002) article on this week’s Learning Resources for guidance on writing case notes using the SOAP format.

Progress Note

Name of Patient:

Date:

Subjective

Amabella suffers from mental distress as a result of being in an abusive marriage for almost fifteen years. Due to the constant abuse, she has developed mild depression as well as anger issues. Her health has deteriorated which has led to weight loss caused by malnutrition.

I have gone through her past medical history in an attempt to investigate any medications she has been under in the past. I have also enquired about any family or social history that would have led to her condition. (Dick, S, 1999, 41)

Objective

Her physical exam findings show that her body is bruised and full of stubborn scars which are a result of being forcefully grabbed or hit with blunt objects. Her neck also reveals that she has been chocked severally. Also, there is a fresh wound cut on her face.

Assessment

The therapeutic sessions have been productive. Amabella is collaborative and is improving. She is open when talking about why she thinks her husband is an animal and whether he can change or not. She does not get as angry and aggressive as she used to when our treatment sessions began. She is now calm, lively and happier. Her health is also improving.

Plan

I have found it very useful to involve a marriage counselor during the therapy to assist because marital issues are beyond my level. I recommended it to her, and she agreed. Afterwards, I have helped Amabella get a competent divorce lawyer who has legally advised her about the whole divorce process as well as her rights upon leaving the toxic marriage. She agrees to this for it is good for the safety of the children and her too. The divorce papers will be ready soon, and she will be moving to her new apartment in a few days.

Privileged Note

Question

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

Answer

My client was troubled at the beginning of our sessions. She disclosed that apart from physical torture from the husband, she was also sexually abused. In fact, the children know what their dad was doing to their mother. She was almost reaching her breaking point, but after completing her therapy, her attitude has changed. Her being able to open up helped a lot.

The above-privileged note includes vital information about abuse in Amabella’s marriage. Sensitive issues like rape are covered, which should be regarded as highly confidential information which should not be disclosed to any other party. (Steen, B, 1999,37)

My preceptor uses privileged notes because I prefer to discuss my issues with him alone because I like my right to privacy to be respected. If other people know my problems, it would increase my mental illness.

References

Dick, R, Steen, E (Editors): 1991. The Computer Based Patient Record; Washington DC, National Academy Press.