Assignment 1: Clinical Hour and Patient Logs
Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion to be counted. You may only log hours with Preceptors that are approved in Meditrek.
Students with catalogue years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course). By the end of Week 1, make sure you confirm your preceptor and clinical faculty are set up in Meditrek.
Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.
Your clinical hour log must include the following:
- Dates
- Course
- Clinical Faculty
- Preceptor
- Total Time (for the day)
- Notes/Comments (including the objective to which the log entry is aligned)
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 patients by the end of this practicum.
The patient log must include the following:
- Date
- Course
- Clinical Faculty
- Preceptor
- Patient Number
- Client Information
- Visit Information
- Practice Management
- Diagnosis
- Treatment Plan and Notes — Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter.
By Day 7
Record your clinical hours and patient encounters in Meditrek.
Clinical Logs: Major Depression
Name: C.Y
Age: 40 years
Diagnosis: Major Depression
S: C.Y is a 40-year-old client that came to the unit for her third follow-up visit, after she was diagnosed with depression four months ago. The client was diagnosed after she experienced symptomsthat included depressed mood in most of the days for every day. She was also socially isolated as he lacked interest in things and pleasure. She reported that the depressed mood had made it difficult for her to engage in her occupational roles.
The client also reported that her ability to make decisions was also significantly affected. He level of irritability was also high. Based on the above, the client was diagnosed with major depression and initiated on psychotherapy and antidepressants.
O: The client appeared appropriately dressed for the occasion. She reported that her mood has been improving with the adopted treatments. The client was oriented to self, others, time, and events. She denied illusions, delusions, and hallucinations. She denied suicidal thoughts and attempts. She denied current suicidal plans. The client does not have a current suicidal plan. Her speech was reduced in terms or rate and volume.
A: The symptoms of depression have improved. The client reports that the treatment has been effective, as she experiences minimal depressive symptoms.
P: The client was advised to continue with the current treatment. She was also advised to come for a follow-up visit after four weeks.
Major Depression
Name: R.T
Age: 40 years
Diagnosis: Major Depression
S: R.T is a 40-year-old male who came to the clinic today for his follow-up visit after being diagnosed with major depressive disorder three months ago. The client has been on antidepressants and group psychotherapy treatments. R.T was diagnosed with major depressive disorder after he came to the clinic with complaints that included the feelings of sadness almost every day. The client also felt intense guilt that made him socially isolated. There was also the change in the sleeping habits of the patient. Accordingly, he noted the increasing difficulties he was experiencing to fall asleep and maintain sleep. The client also reported lack of energy, and suicidal ideations and attempts. There were also the complaints of lack of interest in the social and occupational roles that the patient used to engage in before the diagnosis. Based on the above symptoms, the client was diagnosed with depression and initiated on antidepressants and group psychotherapy.
O: The patient appeared appropriately dressed for the occasion. He was oriented to self, place, time and events. The rate and volume of speech of the patient was normal. The self-reported mood of the client was normal. The client denied illusions, delusions and hallucinations. He also denied recent history of suicidal thoughts, attempts, and plans.
A: The client is responding well to the treatment. The improvement in symptoms is in accordance with the developed treatment objectives. The client is also tolerating the adopted treatment interventions.
P: The decision that the patient continues with the current treatment was made. This was based on the improvement in the symptoms of depression.
Major Depression
Name: D.K
Age: 37 years
Diagnosis: Major Depression
S: D.K is a 37-year-old client that came to the clinic today for the sixth follow-up visit after being diagnosed with major depression seven months ago. He has been on antidepressants and group psychotherapy treatments. D.Kwas diagnosed with depression after she presented with complaints of feeling sad most of the days almost all the days, feeling worthless and guilty most of the times. There was also the complaint of decline in appetite, as she died not want any type of food. Her interest in pleasure also declined significantly.
The client also reported suicidal thoughts without attempts or plans. The symptoms had affected significantly her ability to perform as expected in her occupational roles. The symptoms could not be attributed to other causes such as medication use, medical conditions or substance abuse. She was therefore diagnosed with major depression and has been undergoing treatment in the facility.
O: The patient appeared dressed appropriately for the occasion. She was oriented to self, place, time and events. Her judgment was intact. She denied any suicidal thoughts, attempts or plans as well as illusions, delusions and hallucinations. Her mood was normal.
A: The client has responded well to the treatments. Her mood has improved. She also tolerates the adopted treatments as expected.
P: Psychotherapy sessions were terminated with consent obtained from the client. She was advised to continue with antidepressant therapy. She was scheduled for follow-up visit after two months.
Major Depression
Name: K.A
Age: 28 years
Diagnosis: Major Depression
S: K.A is a 28-year-old male client who came to the unit for her first follow-up visit after being diagnosed with major depression a month ago. The client was brought due to his abnormal behaviors for the last six months. Some of the abnormal behaviors that had been reported during the previous visit to the clinic included losing interest and pleasure. The mood of the client was reported to have been always depressed in most of the days. The client also appeared socially withdrawn, as he did not want to interact with people. As a result, he stayed indoors for most of the times. The client also reported that his mood was severely depressed in most of the days with feelings of worthlessness. When asked about his sleeping and dietary habits, he reported that he rarely slept and had elevated appetite. He was also concerned that his ability to make decisions had worsened significantly over the past, as he found it difficult to concentrate.The client also reported suicidal thought without an attempt or plan. Based on the above data, the client was diagnosed with major depression and initiated on treatment.
O: The client appeared moderately groomed for the clinical visit. His mood was moderately depressed. His insight was normal. His speech was of normal rate and volume. His orientation to self, others, time, and events were intact. The client denied suicidal thoughts plans or attempts since the last visit to the clinic.
A: The client reports moderately improvement in symptoms of major depression. He is also tolerating the adopted treatment interventions.
P: The dosage of antidepressants was increased to achieve optimum therapeutic effect on symptom management. The client was advised to continue with the group psychotherapy sessions. He was scheduled for the next follow-up visit after four weeks.
Generalized Anxiety Disorder
Name: R.T
Age: 22 years
Diagnosis: Generalized Anxiety Disorder
S: R.T is a 22-year-old female client that that came to the clinic for her fourth follow-up visit for generalized anxiety disorder. She was diagnosed with the disorder after she presented to the clinic with complaints of excessive fear and anxiety that was beyond her control. The client also reported that the fear she had was related to her academic performance in the medical school. She was worried that she was likely to fail leading to her losing her scholarship for the program. Symptoms that included palpitations, chest tightness, sweating, and tremors accompanied the feelings of excessive fear. The excessive fear and anxiety had affected significantly the ability of the client to perform optimally in her academic and social roles.
The symptoms could not be attributed to any cause such as medications, medical condition, or substance abuse. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.
O: The client appeared appropriately dressed for the occasion. Her orientation to self, others, time and events were intact. The insight of the client was intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.
A: The client reported that she no longer experiences excessive fear and anxiety. She also reported effectiveness of the psychotherapeutic strategies for managing her problem. The treatment outcomes have been achieved.
P: The participation of the client in group psychotherapy sessions was terminated with her consent. The sessions were terminated because the desired treatment outcomes had been achieved.
Panic Disorder
Name: C.P
Age: 24 years
Diagnosis: Panic Disorder
S: C.P is a 24-year-old male who came to the clinic for a follow-up visit for treatment due to panic disorder. He was diagnosed with the disorder five months ago and has been on treatment. The diagnosis of panic disorder was reached after the client presented with symptoms that included feelings of excessive fear of not performing as expected in his institution. The panic disorder was associated with a number of symptoms. They included palpitations, sweating, trembling, and feeling chocked.
There were also the complaints of chest pain, feelings of chocking, dizziness, and feelings of unreality. The symptoms had affected significantly the functioning of the client. As a result, he was diagnosed with panic disorder and initiated on group psychotherapy.
O: The client appeared appropriately dressed for the occasion. He was oriented to self, space and time. The thought content of the client was normal. He denied illusions, hallucinations, and delusions. The client also denied suicidal thoughts, plans, and attempts.
A: The desired treatment outcomes have been achieved. The client reports effective coping with the distressing symptoms of panic disorder.
P: The psychotherapy sessions were terminated, as the treatment outcomes had been achieved. The client was scheduled for a follow-up visit after two months to assess his coping with the disorder.
Delusional Disorder
Name: D.E
Age: 34 years
Diagnosis: Delusional Disorder
S: D.E is a 34-year-old female client that came to the unit as a referral by her family physician for psychiatric assessment. She came with complaints of feeling that someone is planning to kill. She noted that she has had the feelings for the past year and she often feels insecure about her safety. The client also reported that someone wanted to kill her because of her position in society. She felt that someone targets her due to her immense achievements and the social connections she has with the most powerful people in the community. Further history taking from the client showed that the client has a history of bipolar disorder that has been managed using medications. Based on the above, the client was diagnosed with delusional disorder and initiated on treatment.
O: The client appeared dressed appropriately for the occasion. She was oriented to place, time, and self. She denied illusions and hallucinations. She was delusional. She denied any history of suicidal thoughts, plans, and attempts. Her speech was normal in terms of rate and volume.
A: The client is experiencing symptoms of delusional disorder. In specific, she is suffering from persecutory delusions and grandiose disorders.
P: The client was initiated on individual psychotherapy to address the delusions. The client was scheduled for a follow-up visit after four weeks.
Post-Traumatic Stress Disorder
Name: G.L
Age: 32
Diagnosis: Post-traumatic stress disorder
S: G.L is a 32-year-old female that came to the unit today for her first follow-up visit after being diagnosed with post-traumatic stress disorder. G.L was diagnosed with the disorder following her involvement in a road accident. According to her, she has been experiencing distressing memories about the accident. She has also been experiencing flashbacks and nightmares about the accident. She often engages in activities that divert her attention from the incident. She also reported to have been avoiding any situations that share similarities with the traumatic experience.
The stressful memories and avoidance of situations associated with the accident had affected significantly her ability to perform optimally in her place of work. It also affected her ability to make decisions. Based on the above, G.L was diagnosed with post-traumatic stress disorder and initiated on antidepressants and group psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. She was oriented to self, others, time, and events. Her speech was of normal rate, content and volume. She maintained normal eye contact during the assessment. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts.
A: The client appears to respond well to treatment. She denies any side effects of the antidepressants. She is positive about attending group psychotherapy sessions.
P: The client was advised to continue with the current treatments. She was scheduled for a follow-up visit after four weeks.
Substance Abuse Disorder
Name: L.O
Age: 45 years
Diagnosis: Substance abuse disorder
S: L.O is a 45-year-old male that came today to the clinic for his fifth follow-up visit after being diagnosed with substance abuse disorder. L.O has been on pharmacological treatment and group psychotherapy to help him overcome addiction. He reported that he was diagnosed with substance abuse disorder after he came to the unit with complaints of binge consumption of alcohol. He noted that his alcohol consumption habits were worsening on a daily basis. He often had to increase the amount of alcohol consumed to get his desired level of intoxication.
He also noted that he engaged in practices such as selling family properties and stealing to get money for purchasing alcohol. L.O also reported that he had enrolled in an Alcohol Anonymous group last year with the intention of stopping alcohol consumption. However, he was unsuccessful due to the effects of withdrawal symptoms. He came to the unit for assistance after he found that his binge consumption of alcohol was almost breaking his family. It was also affecting his social and occupational functioning. As a result, he was diagnosed with substance abuse disorder and initiated treatment.
O: The patient appeared appropriately dressed for the occasion. He appeared slightly underweight for his age. His orientation to self, place, time and events were intact. He denied altered thought processes, as evidenced by the absence of illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts. He demonstrated mild tremors during the assessment.
A: The client demonstrates improvement in symptoms when compared to the last visit. He has been actively participating in group psychotherapy sessions.
P: The patient continues to demonstrate improvement in symptoms. He also tolerates the prescribed medications. The client was initiated on Alcohol Anonymous group. He was also advised to continue with the current treatments. He was scheduled for a follow-up visit after four weeks.
Insomnia
Name: E.L
Age: 38 years
Diagnosis: Insomnia
S: E.L is a 38-year-old male that came to the clinic for the third visit after being diagnosed with insomnia. E.L has been on psychotherapy treatment. He recalled that he was diagnosed with insomnia after he presented to the unit with complaints of chronic lack of sleep. He noted that his quality and quantity of sleep started deteriorating six months prior to the visit to the hospital. He reported that he remained awake throughout most of the nights.
He also experienced an awakening in some days, which made it difficult for him to fall asleep thereafter. He had tried using sleep-enhancing medications but they were not effective. The lack of sleep had affected his productivity in the workplace since he often fell asleep during the afternoon hours. Because of the above problems, he came to the unit for assessment where he was diagnosed with insomnia and initiated individual psychotherapy.
O: The patient appeared dressed appropriately for the occasion. He was oriented to self, others, time, and events. His thought content was intact. His speech was normal in terms of rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts. He did not demonstrate any abnormal behaviours such as poor eye contact, yawning, and tremors during the assessment.
A: The psychotherapy treatment appears to be effective. The patient reports a significant improvement in his quality of sleep. He also reports enhanced engagement in occupational activities unlike in the past.
P: The client was advised to continue with the psychotherapy treatment, as it was effective. He was scheduled for a follow-up visit after four weeks.