NUNP 6640 WEEK 7 CLIENT PROGRESS.doc - Assessing Client\u2019s Progress Progress and Privileged Note Walden University NUNP-6640A 1 Assessing Client\u2019s

NUNP 6640 WEEK 7 CLIENT PROGRESS.doc - Assessing Client’s...

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Assessing Client’s Progress Progress and Privileged Note Walden University NUNP-6640A January 11, 2020 1
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Assessing Client’s Progress Progress Note Mental health providers should be aware; documentation is an essential component of client care and treatment plan. Comprehensive progress notes allow for proper diagnosis and treatment of clients with mental health disorders (Nicholson, Ruby, 2002). Also, it assists clients in making informed decisions about their healthcare. All PMHP are obligated to document medical information accurately. In the mental health field, licensed clinical social workers (LCSW) licensed counselors, psychologists and other specialists depend on insightful and comprehensive progress notes and psychotherapy notes to devise individualized treatment plans and medication regimens (Sun & Wasser 2017). Progress and psychotherapy notes are equally essential but vastly distinct. Both must comply with confidentiality guidelines in their way. In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA) to protect the privacy and safety of health information. The Standards for Privacy of Individually Identifiable Health Information, or the Privacy Rule, was issued to implement HIPAA (Nicholson, Ruby, 2002). The purpose of this paper is documentation of the clients' psychotherapy, treatment modality, progress, safety plan and the privileged notes, which may include observations, thoughts of the therapist regarding sessions and hypotheses. SOAP 2
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Assessing Client’s Progress S }25YO Single Caucasian male with a history of Anxiety and Hypertension, a previous history of marijuana uses while in high school. The client became depressed, months ago, after graduating from a military school, no family or friends attended. He proceeded to spend money on frivolous items, such as rims, games and clothes. The client felt his supervisors were harassing him after he was reprimanded for not attending formation and coming to work late several times over 90 days. The client was given Article 15, reduction in pay and given extra duty. The client became despondent, not sleeping not leaving his room and playing video games all day and night. After a thorough assessment, the client was placed in Zoloft on 25mg daily. I inquired about social and family history, and the client drinks caffeinated drinks (red bulls and mountain dews), a six-pack of beer weekly. The client's mother has a history of
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