Nursing Assignment Help and Essay Services - Progress Note

Nursing Assignment Sample - Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

Treatment modality used and efficacy of approach

Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)

Modification(s) of the treatment plan that were made based on progress/lack of progress

Clinical impressions regarding diagnosis and/or symptoms

Relevant psychosocial information or changes from original assessment (i.e., marriage,

separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)

Safety issues

Clinical emergencies/actions taken

Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

Treatment compliance/lack of compliance

Progress Note

Treatment Modality: The treatment modality used is holistic which entails a combination of pharmacology, psychopharmacology, and psychotherapy. The efficacy of this modality is effective in addressing the different patient symptoms and weight issues.

Progress Towards the Patient Goals: Client demonstrates positive progress especially in counselling and medication adherence. Patient notes less commitment to behavioural management and especially diet management. Patient rates achievement of her goals as 50%.

Treatment Plan Modification: Based on the progress, treatment modification entails developing daily eating and exercise targets for the client while working with the gym specialist.

Clinical Impressions and Psychosocial Information: Symptoms have improved significantly. The client is more open and interacts with close family members easily. The client is jovial, and the anxiety has reduced. She has also demonstrated improved social cues and a wider emotional expression. Patient has further formed new relationships and is eager to resume work.

Safety and Clinical Emergency: Patient has not experienced any safety issues or clinical emergencies and has not used other medication besides the one prescribed at the hospital.

Medications: Based on the signed consent, the patient uses the following medications

·        Latuda 20mg1 tablet PO q HS x 7 days, then 2 tablets q HS x14 days for mood stabilization.

·        Lexapro 20 mg 1 tablet PO QD x 7 days, then ½ tablet QD x 7 days for depressive symptoms.

Treatment Compliance: Client shows medication adherence with regards to dosage and time of intake. She also attends all her counselling sessions.

Clinical Consultations and Collaboration: Client has maintained clinical consultations which are beneficial to her health. She contacts the physicians and counsellor when she has a question. Client adheres to the therapist’s recommendations such as ways to overcome anxiety and on behavioural management.

Referrals: Referral to a dietician for developing a meal plan for the weight issue. The referral is centred on the client’s slow response to behavioural management and changes.

Termination Issues: No termination issues reported such as loss of insurance.

Consent Issues: Patient consents to the medication and therapy. No reported issues.

Abuse: No child abuse or adult abuse reported.

Clinical Judgement by the Therapist: Therapist demonstrates good clinical judgement as reflected on the referral and recommendations on ways to address the mood-related challenges and weight issues. 

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