Assignment 2: Practicum 8 - Assessment

Assignment 2: Practicum 8 Assignment 2: Practicum – Assessing Client Progress

There are differences regarding what is documented in the patient’s record and the scribed personal observations of the psychotherapist. This paper will explore the SOAP note by utilizing information from week three. Also, there will be a week-three privilege note constructed, along with a discussion of the differences of the privilege note and the notes made in the patient’s medical record.

Week Three SOAP Note 12/12/19 14:00 (S) "I feel depressed, stressed anxious, and unbalanced." Also, patient stated, "I get shaky and sweaty." Recent History: The patient reports problems in his marriage, intimate relationships, and with others including paranoia, reduced sleep and appetite, worried about finances, excessive talking.

Personal History: The patient had mental treatment at Hospital USA a decade ago. Previous diagnoses include bipolar disorder, schizophrenia disorder, and a history of substance abuse. The patient was raised by both parents, including an older brother and a younger sister. The patient stated that his family moved around a lot, and he "never was stable in school." He was on psychiatric medication as a child and witnessed violence between his parents and violence on the streets where he grew up; additionally, the client reports witnessing a friend overdose on drugs.

The patient stopped attending school around age 13 after he was "put out by school security." He left home at age 13 due to his mother being a heroin addict. (O) Flight of ideas with rapid, loud, paranoid, persecutory thoughts, trouble concentrating, pressured speech, and frequently labile mood (A) Bipolar I disorder, depressed, severe [F31.4, DSM code], and Generalized Anxiety Disorder [F41.1, DSM code]. Clinical impressions: Rule out Bipolar I given the hypomanic symptoms. (P) Rescheduled for 01/12/20 @ 2 p.m.; Prognosis fair, due to the patient's current hypomanic state. Patient to see Dr. N after therapy for psychotropic medication session to review the current medication regimen of Prozac and Trazodone.

Referred to NAMI for family therapy. Next session: Continue cognitive behavioral therapy sessions and assign reading homework: Cognitive-Behavioral Therapy Program–Workbook by Grant, Donahue, and Odlaug.

Part Two: The Privilege Note 12/12/19 14:00: During the meeting with the patient, I noticed that the patient was more manic than usual, which leads me to believe he may not be completely compliant with his medication regimen. Moreover, the patient's marital problems may also be exacerbating his bipolar condition and increasing his insomnia; thus, it may be necessary to review the effectiveness of the current psychopharmacology in the next session.

In summary, I believe that the client has plateaued in his motivation toward his therapeutic goals; nevertheless, I will defer confronting this concern until after reviewing the progress with the patient at the end of the next meeting.

Paper For Above instruction

Understanding the nuances between different types of clinical notes is fundamental to effective mental health documentation. Progress notes, such as SOAP notes, record the clinician’s current observations, patient responses, and treatment plans. In contrast, privilege notes serve as a practitioner's personal, reflective documentation, often emphasizing hypotheses, impressions, and clinical judgments that are not included in official records. This essay explores these distinctions through the examination of a week-three SOAP note and a privilege note, highlighting their respective purposes, contents, and confidentiality implications.

The SOAP note from week three provides a structured, factual account of the patient’s reported symptoms, recent history, personal history, clinical observations, formulations, and treatment planning. It begins with subjective data—the patient's own descriptions of feeling depressed, anxious, unbalanced, shaking, and sweating—offering insight into their lived experience. The note continues with recent and personal histories, revealing contextual factors such as familial background, previous diagnoses, substance use, and environmental influences. Objective findings through mental status examination highlight observable behaviors, affect, speech patterns, and thought processes. The assessment synthesizes these elements into diagnostic impressions, such as bipolar disorder and generalized anxiety disorder, while considering differential diagnoses like bipolar I disorder, given hypomanic symptoms. The plan includes medication review, referral, and ongoing therapy, underscoring a structured approach to care (Cameron & Turtle-Song, 2002).

The privilege note, on the other hand, embodies the clinician’s personal reflections immediately after the session. It notes observations of increased manic behavior, assumptions about medication adherence, and the impact of relational stressors on the patient's mood stability. Unlike the SOAP note, it emphasizes clinical hypotheses and subjective impressions that are not necessarily part of the patient’s official health record. These notes are kept separate from medical records and are protected by confidentiality standards; clinicians must seek patient authorization before sharing privilege notes, and patients generally do not have direct access to them (The Differences Between Psychotherapy Notes and Progress Notes, 2018). They serve as a vital tool for clinicians to track their evolving clinical impressions and inform treatment adjustments in subsequent sessions.

The differences between privilege notes and progress notes are rooted in their purpose and usage. Progress notes aim to document factual, objective, and treatment-relevant information for continuity of care and legal accountability. Privilege notes serve as a clinician’s reflective tool, facilitating clinical judgment and hypothesis formulation that may later influence treatment strategies. For example, a privilege note might record subtle behavioral cues or emotional shifts observed during a session, which may not be immediately reflected in the official record but are valuable for ongoing clinical reasoning (Cameron & Turtle-Song, 2002).

Both types of notes are indispensable to comprehensive mental health care. Proper documentation ensures that patient care is coherent, legally compliant, and ethically sound. Recognizing the distinctions and appropriate usage of these notes enhances clinical efficacy and safeguards patient confidentiality. Clinicians must be well-versed in maintaining these records according to ethical standards and legal regulations, ensuring that personal reflections remain protected and intentioned solely to improve therapeutic outcomes.

In conclusion, while progress notes and privilege notes serve different functions within clinical practice, both are essential components of effective documentation and patient care. Progress notes document the concrete aspects of treatment, while privilege notes provide a confidential space for clinicians to develop insights, hypotheses, and nuanced observations that support ongoing clinical decision-making.

References

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