Mental Health Progress: Placing Patient on Cognitive Behavioral Therapy

Client info:
• Chief complain: Delusion and manic behaviors for 7 days.
History of present illness: Patient is a 26 years old male Caucasian male who presents to HH Main ER with delusional and manic behaviors. Pt's parents called the police because pt has been speaking about bizarre thoughts and ideas for about 1 week and was trying to convince parents he was Jesus and making statements about talking to Donald Trump etc. pt sent from home, lives with parents, police were called, pt is A&Ox4 but very hyper religious, says is recovering opioid addict and has been sent to spread the word of ketamine use to save us all from covid-19, says has spoken with trump and his family.
• Past psychiatric history: Bipolar, Anxiety, delusional disorders. Psychotic, paranoia.
• Medical history: Denied any past medical history.
• Medications:
SEROquel, 50 mg= 2 tab, Oral, q HS, PRN
Tylenol, 650 mg= 2 tab, Oral, q 4 hr, PRN
Zofran, 4 mg= 1 tab, Oral, q 6 hr, PRN.
• Substance use history: Opioids adiction

Part 1: Progress Note

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

• Treatment modality used and efficacy of approach


• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)


• 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)


• The 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 (e.g., 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 family from the Week 3 Practicum Assignment.

In your progress note, address the following:

• 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 family’s progress note.


• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.