MN662 Unit 9 Assignment upload

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School

Purdue Global University *

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Course

MN 662

Subject

Psychology

Date

Feb 20, 2024

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docx

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Uploaded by AdmiralGoldfinch3688

MN662 Unit 9 Follow Up -Therapy SOAP Note Purdue University Global MN662 PMHNP Psychotherapy for Individuals, Groups and Families Clinical January 17th 2024 Student Name: Nadine Williams

Course No. and Section: MN662 Clinical Instructor: Dr. Michelle Kotte Week #: 9 Report to date TOTALS below (hours and patient encounters are logged in CoreElms weekly) Total Clinical Hours for this Week: 130 Total Clinical Hours for this Course: 130 Total Clinical Hours for the PMHNP Program: 520 Patient Name: Jill

MRN: 12052023 Date of Service: 12/12/2023 Start Time: 11:00 End Time: 12:00 Billing Code(s): 90837 Psytx w pt. 60 minutes Accompanied by: Self CC: Follow-up visit HPI: Chief Complaint: per parent "CH will stop being defiant and unruly and learn to listen to his parent and teacher. 90847 family psychotherapy services F91.3 Oppositional defiant disorder Z71.51 Drug abuse counseling and surveillance of drug abuser CH is a 17 year old African american male, he is acompanied by his mother, presented for the family counseling telehealth session. the mother reported that currently the client keeps taking his clothes off and on. Client was reported to being very anxious and out of control. Parent reported that she was contacted by the client's school to get him due to disturbing behavior, included throwing trashes in the school stairs and will not control his behaviors. Client affect was not congruent. and his disposition was not mentally stable. Client exhibited auditory or visual hallucinations but did not verbalize any homicidal or suicidal ideations. Client's thoughts processes were incoherent as evidenced by his repetitive actions that his parent reported being abnormal. Client Client was oriented to person, place, but had a different perception of time and situation. patient is dressed appropriately for the season, well groomed. Behavior cooperative, speech and tone is normal, poor insight and judgement poor. Based on the assessment completed today, patient is not found to have an imminent threat of death by suicide nor is patient found to have an imminent threat of harm to others. Intervention: Therapist conducted the family counseling session via telehealth/zoom with the client mother verbal consented. Therapist used motivational interviewing to assess client's continues progress towards changing. Therapist Using CBT techniques engaged client in a discussion focused on decreasing

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racing and current psychosis symptoms to apply a more constructive response when he experiences those negative behaviors. Therapist assisted client through the process of evaluating his responses to include a consistent engagement in healthy coping skills to self-regulation to minimize the triggers that makes him hallucinates. Therapist provided the client's mother with psychoeducation on meditation and other coping techniques to help rechanneled those unwarranted responses to learn stay calmed and balance. Therapist uses modeling and behavioral rehearsal to train the client positive self-talk that reassures him of the ability to endure anxiety symptoms without serious consequences. Response: During the family session, the client continues experiencing symptom s of psychosis and delusions. Client statement when answered therapist were not coherent. Client actions were irregular as was picking up small trash items to put in the garbage bin. He takes off his clothes repeatedly and put them back on. Mother reported that client has not slept and refuses to stay still. Parent reported he will have no choice but to take the client to the hospital. Mother reported that the client has not stated any SI or HI during the thought's disturbance. . Parent agreed that she cannot stabilized the client even with the administered medication to control his mood. Mother continued the telehealth zoom while in route to CHOA/children hospital and she arrived there safely with the client to be assessed. Plan: Therapist will utilize CBT is a form of talk therapy to educate client to look process his thoughts, feelings, and behaviors and replace negative thoughts with more realistic, positive ones, ST will follow up with the client's mother to monitor the client's mental health crisis condition at this time. Over the next 180 days client will reduce the frequency of unruly and defiant behavior that causes to get in trouble at home and in school. Therapist will utilize CBT is a form of talk therapy to educate client to look process his his thoughts, feelings, and behaviors and replace negative thoughts with more realistic, positive ones and guide him to change behaviors that cause problems in everyday life from 2-3 to improve to 0 at home and school. Progress: Consumer met his/her goal this session: Goal: To stay out of trouble

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