Assignment 1: Practicum – Assessing Client Family ProgressLearning ObjectivesStudents will:· Create progress notes· Create privileged notes· Justify the inclusion or exclusion of information in progress and privileged notes· Evaluate preceptor notesTo prepare:· Reflect on the client family you selected for the Week 3 Practicum Assignment.AssignmentPart 1: Progress NoteUsing the client family from your Week 3 Practicum Assignment,( Will Attach) 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 judgmentNote: Be sure to exclude any information that should not be found in a discoverable progress note.Part 2: Privileged NoteBased 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.Resources ( need 3 references).American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Boston, MA: Pearson.Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Assignment 1: Practicum – Assessing Client Family Progress Learning Objectives Students will: · Create progress notes · Create privileged notes · Justify the inclusion or exclusion of information in p
FAMILY THERAPY 7 Family Therapy Part 1: Family Therapy Demographic information JM, 30 years old African American male presented to therapy due to drunk driving with his daughter J 5 years old in the car. JM was taken to jail while his daughter was taken to the custody of her cousin. JM was happily married to HM for seven years before her death one year ago due to a short illness. JM was a worker at a processing company previously and this year was dismissed from work due to alcohol-related issues. Medical history JM has no serious underlying medical conditions, but he suffers a mild headache from time to time which he does not take any medications. Substance use history JM confessed that he has no history of alcoholism before the death of his wife, after her death JM mostly drinks about five standard cups of beer during weekends to relieve him from stress. No drug or substance use. Presenting problem Previously JM had a case of DUI reported and charged for the offence. He was detained for drunk driving in the accompaniment of his daughter J, a minor onboard. The incident was also perceived as endangering his life and that of the child, due to impairment. He was charged with the offence and jailed, but he feels he is ready to change. He prefers lesser punishment rather than jail so he can take care of his daughter. JM had recurrently refuted being alcoholic even though accepted claims that he was drunk during the incident. He was examined to have a blood-alcohol quotient of nearly three times the standard limit. The child protective service officer concluded that JM was not capable of taking care of J, due to his occasional intoxicating behavior which endangers the child. The officer mandated JM to attend family group therapy for 10 weeks, to enable him recover from alcoholism and embark on good parenting habits. He was also required to undergo therapy to help him come into terms with the death of his wife a year ago. JM also had been dismissed from his job due to drunkenness at the job. This was also a troubling issue that probably led him deeper into alcoholism. Family psychiatric history His family opened about his struggles with life after his wife died; they cited that it affected his life status negatively. He felt left alone in raising their daughter and at the same time, commitment to his job. They said he was later dismissed from his work; with an agreement he seeks intervention from a psychiatrist and reports later to work after therapy. Psychiatric history JM’s has a family history of drug and alcohol abuse. His grandfather was a known alcoholic, with cases of violent behavior, and died due to alcohol-related illnesses. His father, moreover, was addicted to smoking cigarettes. The pattern continued among various members of the family, including JM. But he had not shown this behavior of alcoholism until the death of his wife. Developmental history According to (Elliott & Bowen, 2018), It is observed that the case of alcoholic behavior could cause a state of negligence of duties as one could not be responsible enough for the growth of their kids. At the same time, JM’s arrest and jail also contribute further to separation with his daughter. This could affect deeply emotional development of J, losing her mother and father almost at the same time. Since the kid had already an emotional connection with the father, jailing him could mean a longer separation period, hence inadequate parental love. Physical assessment JM had no physical symptoms or distress on inspection. Treatment plan The treatment plan was organized into ten sessions of therapy for three months. The main reason for JM’s drinking predicament and wife’s death related trauma was addressed. The approach used was to help Mr. JM address the stress associated with death and how it occurred. This helped him to reinvest in his life in better ways that are fulfilling to him. The treatment was composed of three core mechanisms; 1) building internal and interpersonal resources; 2) processing the traumatic death both cognitively and emotionally and 3) moving through the process of grieving (Johnson, 2019). According to Manuel & Deren (2017), a supportive therapeutic relationship is necessitated in the process. During the session, MJ would be granted visitation rights; he could meet with his daughter and spend some time together. His recovery process is directly influenced by the need to take care of his daughter, the need to be a responsible and a more careful father. Case formulating In this case, the child’s best interest comes first. It is a mandate for the court system not to separate the father from his child especially in this situation where it was determined that JM was not in a serious state of alcohol addiction, but just a case of an unaddressed traumatic event. Consequently, he would regain full custody rights of his daughter once he is done with the mandated therapy sessions. Part 2: Family Genogram Conclusion According to research, attending group therapy is a successful way of addressing alcohol and drug abuse-related issues with others facing the same challenges. Although JM does not have his child with him, therapy will help him focus on healing and learning more coping skills and to become a better person. References Elliott, S., & Bowen, S. (2018). Defending motherhood: Morality, responsibility, and double binds in feeding children. Journal of Marriage and Family, 80(2), 499-520. Johnson, S. M. (2019). The practice of emotionally focused couple therapy: Creating connection. Routledge. Manuel, J. I., Yuan, Y., Herman, D. B., Svikis, D. S., Nichols, O., Palmer, E., & Deren, S. (2017). Barriers and facilitators to a successful transition from long-term residential substance abuse treatment. Journal of substance abuse treatment, 74, 16-22.
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