Progress and Privileged Notes Counseling Client Families

Case Summary
Client Y is a 33-year-old African-American female with two children aged 3 and 5, and married to a 39-year-old Hispanic male. Client Y presents following a referral by her sister, who thinks that she is under severe emotional distress. Symptoms at the time of presentation included a depressed mood, inability to concentrate, nightmares, sleeping difficulties, and heightened irritability. Client reported that symptoms began 4 months earlier, after a violent encounter with her husband that resulted in serious injury. Client Y was diagnosed with PTSD and placed on Sertraline (Zoloft) 25 mg once daily in addition to once-weekly CBT sessions. The goal of treatment is to ensure that client Y regains control over her life and develops skills to address her symptoms. Four weeks later, the client shows minimal response to treatment. PTSD symptoms are still present. No modifications have been made to the treatment plan this far.
Subjective Content
The client reports that she is still unable to concentrate, feels depressed most of the day, and has not noticed any improvement in regard to the nightmares. She reports feeling like a ‘ship lost at sea – afraid of a pirate attack at any time’ as she constantly fears that she could wrong her husband and attract another violent attack. The client reports that she is able to fall asleep more easily over the past two weeks and no longer experiences night chills and sweating, although she fears going to bed as the nightmares keep coming. She is ‘willing to do anything for the nightmares to go away and for her days and those of her family to be bright again’. The client is concerned that the prescribed medication is ‘working too slowly’.
Treatment Compliance
The client reports that she had been taking her medication as prescribed until a week ago, when she began feeling like it had ‘no impact’. She now takes the medicine only when she remembers. Client has not taken any other medication since she began treatment with Sertraline.
Relevant Psychosocial Information
The client’s relationship with her husband is getting worse as she ‘no longer loves her husband like she used to’. Her interactions with male clients have been severely affected and she fears that this is hurting her business. She is concerned that she may lose some of her key clients as she has had to halt associations with particularly male clients. Her relationship with her children has also suffered as she no longer takes time to cook nice meals for them or treat them during the weekends.
Safety Issues
The client does not report any safety concerns from her use of Sertraline. Client does not report heart palpations, chest pains, or breathing difficulties. No clinical emergencies have been reported.
Objective Content/Clinical impressions
The client is well-groomed, though irritable and distracted. She is fully communicative, although her speech rate is slow and incoherent. She constantly avoids eye contact and her reasoning and thought processes are at times illogical. She displays a depressed mood and is delusional, especially in regard to the way married couples ought to relate. Insight and judgment are intact, and the client denies homicidal or suicidal ideation. She appears aware of her existence, though unaware of some of her thoughts.
Analysis
The client has not reported any adverse effects due to the use of Sertraline this far. This could be a positive sign, but also a likely indicator of insufficient dosage. Although the expected treatment goal has not been realized, it is not advisable to change to another SSRI at this point as the effectiveness of Sertraline has not been adequately tested. Clinical trials have shown that treatment gains of SSRIs are realized in between 6 and 8 weeks (Sanchez et al., 2014; Fergusson, 2013). The most plausible decision thus would be maintain Sertraline, but increase the dosage for a further four weeks.
Plan/Recommendations
Client and PMHNP agree that little progress has been made towards attaining the expected treatment goal.
PMHNP Recommends as follows:
i) Increase the dosage of sertraline from 25mg to 50mg daily
ii) Introduce twice-weekly CBT sessions to replace the current weekly sessions. Studies have shown that twice-weekly CBT sessions are more effective and lead to more rapid recovery of depressive symptoms that once-weekly sessions (Bruijniks et al., 2015).
iii) Client returns for review in 4 weeks
Target Date: 20/02/2021
Client agrees with these recommendations.
Short-Term Goal
With the increased Sertraline dosage and twice-weekly CBT sessions, the PMHNP expects client Y to report a 50 percent remission of PTSD symptoms by the time of the next visit.
Collaboration with Other Professionals
i) PMHNP will contact a nutritionist the following week to help the client in weight-management. Weight gain is a common adverse effects of Sertraline, and there is the risk of the client’s obesity worsening as a result of sustained SSRI use (Shi et al., 2017).
ii) PMHNP to contact a family counselor the following week to plan for joint therapy and anger-management sessions for the client and her husband
Referrals
i) PMHNP refers the client to a fitness program in the locality to help her better manage her weight
Consent and Termination
Client willingly consents to the prescribed treatment plan: Yes…………… No………………
Treatment costs are to be covered either out-of-pocket or through health insurance.
In case of loss of insurance, client will be notified, and treatment terminated within 14 days of such notification
Return after 4 weeks or earlier if need be
Time Spent Counseling: 45-50 minutes
Session Start: 11am
Session End: 11.50am
XXX (Counselor’s Name)
Electronically signed
By: XXX
On 20/01/2021, 12.30pm
Part 2: Client Family Privileged Note
Privileged Note
Patient ID: Client Y
Patient Number: 100000006789
The client family is dealing with anger-management issues that may need to be addressed for effective physiological functioning during and after the current treatment. In this regard, there is a need to enroll the client’s husband to an anger-management program. At the same time, the parent client’s social life has been significantly affected by the traumatic event that she went through. It may be important to boost the client’s self-esteem and enhance her self-confidence to help her appreciate herself as an important party in the marriage. As the parent client is not a very social person and has few friends, there may be a need to encourage more communication and interaction with her parents, both of whom are alive. The parents could provide a listening ear for the client, thus minimizing the risk of piling things up and heightening stress/ depression. More communication with the parent clients’ parents and other couples that have had successful marriages could also be crucial in helping client Y change her mind set on how marriage couples need to interact with each other.
The progress note documents the client’s clinical progress and can be accessed by any authorized medical personnel. For instance, a therapist may share a progress note with another therapist as a way of acquainting them with the client’s medical history. Its main aim is to document a client’s clinical progress in the course of treatment. Conversely, a privileged note is private (Corley, 2013). As such, it would not include medication details, test results, treatment plan information, summary of diagnosis, or summary of clinical progress, all of which would be present in a progress note. Some of the information present in the progress note is excluded from the privilege note as privilege notes are private notes that are not subject to federal privacy protections. My preceptor uses privileged notes in their interactions with clients. The notes include subjective information such as the therapist’s personal observations about a client (family), hypotheses, questions for supervisors, and feelings or thoughts related to the therapy sessions.
References
Bruijniks, S. E., Bosmans, J., Peters, F.,…& Huibers, M. (2015). Frequency and Change Mechanisms of Psychotherapy among Depressed Patients; Study Protocol for a Multicenter Randomized Controlled Trial Comparing Twice-Weekly Versus Once-Weekly Sessions of CBT and IPT. BMC Psychiatry, 15(1), 137-47.
Corley, S. O. (2013). Protection for Psychotherapy Notes under HIPAA Privacy Rule: As Private as Hospital Gown. The Journal of Law-Medicine, 22(2), 489-534.
Fergusson, J. M., (2001). SSRI Antidepressant Medications: Adverse Effects and Tolerability. Primary Care Companion to the Journal of Clinical Psychiatry, 3(1), 22-27.
Shi, A., Atlantis, E., Taylor, A. W., Gill, T., Price, K., Appleton, S., Wong, M., & Licinio, J. (2017). SSRI Antidepressant Use Potentiates Weight Gain in the Context of Unhealthy Lifestyles: Results from a 4-Year Australian Follow-Up. BMJ Open, 7(8), doi: 10.1136/bmjopen-2017-016224
Sanchez, C., Reines, E. H., & Montgomery, S. (2014). A Comparative Review of Escitalopram, Paroxetine, and Sertraline. International Clinical Psychopharmacology, 29(4), 185-96.