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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 from the Week 3 Practicum Assignment. (THE WEEK 3 ASSIGNMENT IS ATTACHED)

· The privileged note should 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’s progress note.

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

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

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)

Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.

Running head: THE HERNANDEZ CASE STUDY 1

THE HERNANDEZ CASE STUDY 9

Running head: HERNANDEZ CASE STUDY 1

The Hernandez Case Study

Damian Ngodo

Ngododamian@hotmail.com

Cufa Behavioral Services Inc Festus Uzokwe (MD)

(713) 360-7972

Bigardconnect@yahoo.com

October 14, 2017

HERNANDEZ CASE STUDY 2

The Hernandez Case Study

Part 1: Comprehensive Client Family Assessment

Demographic information

Juan Hernandez Junior is an 8-year-old, Latino, male.

Presenting problem

Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.

History or present illness

Parent’s reports Hernandez has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged in 2010.

Past psychiatric history

Parents report that Juan Jr. has been of sound psychiatric health.

HERNANDEZ CASE STUDY 3

Medical history

Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.

Substance use history

Both parents have no history of substance abuse nor does Juan Jr.

Developmental history

Parents reports no delays

Family psychiatric history

Parents report no psychiatric problems in their family history.

Psychosocial history

Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.

History of abuse/trauma

Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.

Review of systems

Gen: Has no fever, night sweats, heat intolerance, weakness or fatigue.

HERNANDEZ CASE STUDY 4

Head: No migraine headaches reported.

ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.

Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, and hypertension.

GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, and change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

HERNANDEZ CASE STUDY 5

47 Height: inches

Weight: 129lbs

Temp: 37 0C.

RR: 16

BP: 120/59

Pulse: 79 BPM

Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.

Mental status exam

The whole family comes to the appointment since they should do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.

Differential diagnosis

The parents grew up too fast and are projecting their feelings on their children.

Diagnosis

Anger Management issues

Case formulation

The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27-year-old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he should do

daily. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend.

HERNANDEZ CASE STUDY 6

On the other hand, Elena is a 25-year-old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.

Treatment plan

Treatment Goals

The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family come to terms with the situation at hand.

Estimated Completion: 3 Months

Objective #1

The parents will be able to discipline their children effectively and using safe options.

Treatment Strategy / Interventions: This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting

limits like taking away their privileges and using time-out. This can only be successful if the parents fully understand the age appropriate behavior of each stage s they do not cross boundaries and punish them unnecessarily.

Estimated Completion: 3 Months

Objective #2

In the end, the parents should be able to find child development techniques that will boost their children’s self-esteem and ensure they have a strong sense of confidence. They should also be able to manage their frustrations as a family.

HERNANDEZ CASE STUDY 7

Treatment Strategy / Interventions: Through role playing, both the parents and the children are able to find a way to understand the feelings of the other so they can rectify any issues they might have had. This will help ensure order at home is maintained without the need for discipline and that the parents do not put unrealistic expectations on their children.

Estimated Completion: 3 Months

Social Support system:

Friends and family

HERNANDEZ CASE STUDY 8

Part 2: Family Genogram includes Juan Hernandez Junior’s family.  

Paternal grandparents’ maternal grandparents

Hernandez’s uncles Hernandez’s father Hernandez’s mother Aunt

His brother Hernandez Hernandez’s sister

Sister in-law

His nephew

HERNANDEZ CASE STUDY 9

Reference

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

 

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