Running head: ASSESSING CLIENT PROGRESS

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Name
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Institution
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 ASSESSING CLIENT PROGRESS 2

Assessing Client Progress

Part 1: Progress Note

Patient selected in week three was A.S a 27 years old African American woman who

presented in the facility feeling sad, guilty, poor appetite, lost her job, has no source of

income, and she also lost interest in social activities and was diagnosed with Major

Depressive Disorder (MDD).

Treatment modality used and efficacy of approach

The treatment modality used for the patient was Cognitive Behavioral Therapy (CBT)

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and support groups. The importance of the talk psychotherapy is that it helps in modifying the

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negative behaviors, attitudes, and thoughts of the patients together with the patient emotional

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response, which leads to psychological distress.
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Progress and/or lack of progress toward the mutually agreed-upon client goals
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(reference the Treatment plan—progress toward goals)

Through the patient progress, the goals which were set were adequately met. Through
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CBT, it helped in changing the patient negative thoughts together with issues that relate to
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stress, depression, and anxiety. The patient also reported that her symptoms had improved

and she also reported positive effects of the treatment. She also reported that her depression
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level had reduced, has stopped taking illicit drugs, and her social life has changed since she
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now has social connections with people.

Modification(s) of the treatment plan that were made based on progress/lack of progress

There was no modification of the treatment plan towards the patient since she had

already started showing positive results.

Clinical impressions regarding diagnosis and/or symptoms

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 ASSESSING CLIENT PROGRESS 3

The clinical impressions regarding diagnosis and symptoms included the use of

clinical judgment towards assessing the patient symptoms together with deducing the

treatment modalities. The other clinical impression was the use of PHQ-9 score towards

testing and confirming the patient diagnosis for Major Depressive Disorder together with

excluding the other medical health disorders from the patient which are causing the patient to

feel depressed together with being sad, guilty and having a poor appetite.

Relevant psychosocial information or changes from original assessment (i.e., marriage,

separation/divorce, new relationships, move to a new house/apartment, change of job,

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From the original assessment, there are no changes.

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The previous information showed that the patient had some suicidal ideation due to
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the negative experiences that she encountered, and this led to the patent being advised to have
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a nanny who would help in taking care of the patient children.

Clinical emergencies/actions taken

Even with the client engaging in excessive illicit drug use, she was not consuming any

medication to change her behavior and improve her deteriorating health style.
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Medications used by the patient (even if the nurse psychotherapist was not the one

prescribing them)

The assessment showed that the patient was substantially compliant with the

treatment approaches offered to her and that she was able to attend all her CBT sessions and

the support groups sessions on time and with efficiency.

Treatment compliance/lack of compliance

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 ASSESSING CLIENT PROGRESS 4

There were some clinical consultations by the patient to ascertain the effectiveness of

the treatment which she was being offered. The patient was allowed to engage in consultation

by using emails, physical consultation with the primary provider, and using phone calls when

she needed clinical guidance.

Collaboration with other professionals (i.e., phone consultations with physicians,

psychiatrists, marriage/family therapists, etc.)

The other professionals who were included in the patient treatment plan were the

nutritionist to help in improving the patient appetite level and the family therapist. The

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nutritionist guided the patient on the diet and activities that she should be taken, especially

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after she controlled her intake of illicit drugs, which were taking a toll on her body weight.

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Therapist’s recommendations, including whether the client agreed to the
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recommendations
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The therapist recommended that the patient need to seek assistance from close family
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members and friends. Always consult with the nutritionist on the best way to improve her

body by taking a balanced diet. The therapist also recommended the patient to adhere to the
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CBT sessions and always consult the primary care provider when she has any medical issue.
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Referrals made/reasons for making referrals

There were no referrals made to the patient.

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)

After assessing all the information about the patient, there were no termination issues

occurred in the patient.

Issues related to consent and/or informed consent for treatment

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 ASSESSING CLIENT PROGRESS 5

The issue relating to consent and informed consent for treatment is that the patient

was educated before being engaged in the treatment approaches and goals which led to her

acceptance of the treatment approaches through signing the informed consent form.

Information concerning child abuse, and/or elder or dependent adult abuse, including

documentation as to where the abuse was reported

There was no information concerning child abuse or elderly abuse from the patient.

Information reflecting the therapist’s exercise of clinical judgment

Clinical judgment is often reflected in the therapist collection and analyzing the

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patient chief complaint, all the subjective and objective data child helped to explain that the

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illicit drug use by the patient led to her developing Major Depressive Disorder (Shaban,

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2015). Clinical judgment is also highlighted through the therapist deducting the treatment
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plan that is based on the patient presented signs and symptoms.
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Part 2: Privileged Note

The privileged note should include items that you would not typically include in a note
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as part of the clinical record.

The patient had no medical history, but it can be deduced that through her illicit drug
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use and being born from a family which the grandmother had dementia and depression it can
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be said that it worsens the situation leading to the patient developing MDD. The physical

examination showed that the patient was distress, especially since she was not able to get a

job. The patient collaboration with the treatment plan would help in effectively solving the

psychological issues that she had developed.

Explain why the items you included in the privileged note would not be included in the

client’s progress note.

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 ASSESSING CLIENT PROGRESS 6

The items in the privileged note would not be included in the progressive client note

as they consist of important information regarding the patient use of illicit drug and the

family having issues of depression. They don't show how the patient is progressing currently.

Explain whether your preceptor uses privileged notes, and if so, describe the type of

information he or she might include. If not, explain why.

My preceptor utilizes privileged notes, and this includes hypothesis on the diagnose,

observation, and the emotions about the patient medical conditions. The privilege notes, need

always to be kept away from any medical records and billing information relating to the

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patient. Information that need to be include are providers observations, hypothesis and the

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questions that the preceptors of supervisors need to be asked (Mills, 2015).

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References
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Mills, J. (2015). Psychotherapist-Patient Privilege, Recordkeeping, and Maintaining

Psychotherapy Case Notes in Professional Practice: The Need for Ethical and Policy

Reform. Canadian Journal of Counselling and Psychotherapy/Revue canadienne de

counseling et de psychothérapie, 49(1).

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 ASSESSING CLIENT PROGRESS 7

Shaban, R. (2015). Theories of clinical judgment and decision-making: A review of the

theoretical literature. Australasian Journal of Paramedicine, 3(1).

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