Practicum Experience Time Log And Journal Template ✓ Solved
PRACTICUM EXPERIENCE TIME LOG AND JOURNAL TEMPLATE
The purpose of this week’s journal entry is to discuss the two clients that I have observed and counseled this week during my practicum experience, who have attended the same family session and Group Therapy. The Progress Notes of the family session will be documented in accordance to this week’s learning Resources. The clients are described and identified with their pertinent history and medical information, including prescribed medications and using the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5), to explain and justify my diagnosis for the two clients and to explain any legal and/or ethical implications related to the counseling of the two clients.
Documentation Skills to Examine Family Therapy Sessions
Documentation skills are essential skills required to examine Family Therapy Sessions. Documentation responsibility could be overwhelming considering the workload of therapist and advance practicing nurse performing psychoeducation and psychotherapy for individuals and groups of patients and clients. The documentation includes client’s notes, referrals, billing, treatment plans, and collaterals. To examine the family sessions effectiveness, it involves the development of session checklist, learning about the State’s documentation laws and rules, completing session notes with client’s, scheduling note writing time, and setting phone hours.
According to Bowen’s theory, family is the natural system of relationships playing an important role in guiding clinical approach and psychotherapeutic care of the client and providing required intervention for patient care.
Client 1 Observed and Counseled this week during the Family Therapy
The client, LT, is a 13-year-old Caucasian female who lives with her father, diagnosed as a bipolar individual several years before the girl was born. The client was admitted to the acute care unit. The client’s chief complaint is missing school, waking up sad and constantly getting into arguments with the father, and self-inflicted pain. The client presented with Major Depressive Disorder (MDD), Attention-Deficit/Hyperactivity Disorder (ADHD), and self-harm. The client denies violence, sexual aggression, or victimization and currently does not present a risk of elopement.
The history of hospitalization from age 12 includes symptoms of increased anxiety and mood swings. The client admitted to low academic engagement and reported bad news regarding her best friend, impacting her adherence to the medication regimen for four days. She indicated her friend was impregnated by her uncle, which caused distress and contributed to her feelings of instability.
Current Medications
LT is currently prescribed several medications, including Trazodone, Vyvause, Hydroxyzine, Quetiapine, and Escitalopram, addressing her anxiety, mood, and depression.
Justification of Diagnosis
The diagnosis for LT is MDD, and it meets the DSM-5 criteria due to the presence of five or more symptoms related to depressed mood, insomnia, fatigue, feelings of worthlessness, and thoughts of death.
Client 2 Observed and Counseled
The client, DA, is a 14-year-old Caucasian female living with her stepfather and mother, with a history of depression and suicidal attempts. The client has suffered from hopelessness and anxiety and was diagnosed with a major depressive disorder. DA expressed frustration with her family dynamics and described feelings of disconnection and a lack of support from her parents.
Past Medical History
DA has no significant medical history or reported substance use. She was discharged to go home with her mother, despite expressing dissatisfaction with this arrangement.
Justification of Diagnosis
DA’s diagnosis is also MDD Severe, Recurrent, without Psychosis, substantiated by the presence of symptoms outlined in the DSM-5, including consistent feelings of sadness, insomnia, and suicidal ideation.
Legal and Ethical Implications Related to Counseling Clients
Legal and ethical implications are crucial in the counseling field. Issues include patient privacy and family confidentiality, as mandated by the Mental Healthcare Act of 2017 (MHCA 2017). Respecting patient autonomy and ensuring informed consent are fundamental ethical obligations of mental health professionals.
Practitioners must navigate the complexities of individual and shared therapy settings, ensuring that the rights of all participants are upheld while addressing any legal requirements tied to minor patients.
Conclusion
This practicum experience underscores the vital role of proper documentation, ethical considerations, and a thorough understanding of each client's history and context in providing effective mental health care.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author.
- Bipeta R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal of Psychological Medicine, 41(2), 108–112.
- National Institute of Mental Health (NIMH). (2018). Depression. Retrieved from [NIMH website].
- Parekh, R. (2017). Depression. American Psychiatric Association (APA). Retrieved from [APA website].
- Papero, D. V. (2014). Assisting the Two-Person System: An Approach Based on the Bowen Theory. Australian and New Zealand Journal of Family Therapy.
- Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
- Walter, I. R. (2016). 5 Tips for Keeping Up with Therapy Paperwork. Family Therapy Basics.
- Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
- American Academy of Child and Adolescent Psychiatry. (n.d.). Ethical issues in clinical practice. Retrieved from [AACAP website].
- Centers for Disease Control and Prevention (CDC). (2020). Mental health surveillance among children – United States, 2013. Retrieved from [CDC website].