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 catalog 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.

Please complete this assignment for 10 different patients thanks
MY CLINICAL PRACTICUM IS A PRIVATE PRACTICE , MY CLINICAL WORKING HOURS WILL BE Thursday AND FRIDAY 8 AM- 5 PM,
I WILL BE WORKING ALONG WITH MY PRECEPTOR WHO IS A PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER.

MY CLINICAL SITE IS A PRIVATE PRACTICE THAT PROVIDES DIRECT CLINICAL SERVICES SUCH AS PSYCHIATRIC EVALUATION, CRISIS INTERVENTION, PSYCHOPHARMACOLOGY TREATMENTS, AND REFERRALS AS NECESSARY TO PATIENTS WITH DIFFERENT PSYCHIATRIC DIAGNOSES.

ON EACH OF MY CLINICAL DAYS I WILL BE SEEING 5 PATIENTS AT MY PRACTICUM PER CLINICAL WHICH MEANS THAT I WILL HAVE TO WRITE 5 DIFFERENT PATIENT NOTES.

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Solution

 

Name: C.H

Age: 32 years

Diagnosis: Schizophrenia

S: C.H is a 32-year-old female that came to the unit for her third follow-up visit after being diagnosed with schizophrenia four months ago. The diagnosis was reached after presenting with complaints that included seeing imaginary things and hearing voices for more than five months. She also reported a significant decline in her functioning in areas that included interpersonal relations, work, and self-care due to the above symptoms. A further assessment demonstrated that the symptoms could not be attributed to causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with schizophrenia and initiated treatment.

O: The client appeared well-groomed for the occasion. She was oriented to space, time, events, and self. C.H denied any recent experience of illusions, delusions, and hallucinations. She denied suicidal thoughts, attempts, and plans. The client’s thought content was future-oriented.

A: The client continues to demonstrate improvement in the symptoms of schizophrenia.  She also tolerates the prescribed treatments.

P: The client was advised to continue with the prescribed medications and psychotherapy sessions. She was scheduled for the next follow-up visit after four weeks.

 

Post-Traumatic Stress Disorder

Name: A.Y

Age: 50 years

Diagnosis: Post-traumatic stress disorder

S: A.Y. is a 50-year-old male that came to the unit today for his third follow-up visit after being diagnosed with post-traumatic stress disorder four months ago. A.Y was diagnosed with the disorder after experiencing abnormal symptoms following his involvement in a road accident. He reported distressing memories that related to the accident. He also reported flashbacks and nightmares about the accident. The above symptoms had made him engage in activities to divert his attention from any stimuli related to the incident. The stressful memories and avoidance of situations associated with the accident significantly affected his ability to perform optimally in his social and occupational roles. As a result, he was diagnosed with post-traumatic stress disorder and initiated on antidepressants and group psychotherapy sessions.

O: A.Y. appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His thought process was future-oriented. His mood was euthymic. He denied any recent suicidal thoughts, plans, or attempts. He also denied illusions, delusions, and hallucinations.

A: The adopted treatments are effective in symptom management. A.Y. also reports minimal side effects associated with the prescribed antidepressants.

P: A.Y. was advised to continue with the currently prescribed medications. He was also advised to continue with the psychotherapy sessions. He was scheduled for a follow-up visit after four weeks.

 

Obsessive-Compulsive Disorder

Name: D.O

Age: 32 years

Diagnosis: Obsessive-compulsive disorder

S: D.O is a 32-year-old female who came to the clinic for psychiatric assessment after being referred by her physician. She came with complaints of experiencing intrusive, unwanted behaviors. She also reported that the behaviors were associated with high levels of distress and anxiety. She had unsuccessfully adopted diversion behaviors to manage them. There were also complaints of compulsive behaviors that included frequent checking things that consumed her time. She always felt the urge to keep checking things, as she believed they were not done to the expected standards. The obsessions and compulsive behaviors were adversely affecting her social and occupational functioning. She, however, asserted that the obsessive and compulsive behaviors were false. Further assessment of the client showed that the above symptoms could not be attributed to any other mental disorder such as depression and mania. As a result, she was diagnosed with obsessive-compulsive disorder and initiated on psychotherapy.

O: The client appeared well-groomed for the occasion. She was oriented to self, others, events, and time. Her thought content and process were intact. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, plans, and attempts.

A: The client is willing to participate in any treatment that would help her overcome the intrusive and distressing symptoms.

P: The client was initiated on group psychotherapy sessions. She was scheduled for a follow-up visit after four weeks.

 

Depression

Name: X.T

Age: 36 years

Diagnosis: Depression

S: X.T. is a 36-year-old female who came for his second follow-up visit. She was diagnosed with depression three months ago. The diagnosis was reached after the client complained of frequent emotional outbursts. She was also easily irritated alongside feeling hopeless and guilty. X.T also lacked interest in things and pleasure.  The additional complaints raised included insomnia, lack of energy, and difficulties in making decisions.  The symptoms could not be attributed to substance abuse, medication, or mental health problems. As a result, she was diagnosed with major depression and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. She was oriented to place, self and time. Her speech was normal in terms of volume and rate. She denied any recent history of hallucinations, delusions, illusions, or suicidal thoughts and attempts. Her thought content was intact. The mood was normal.

A: The client appears to be responding well to pharmacological and psychological treatments, as evidenced by symptom improvements.

P: The client was advised to continue with the current dosage of Zoloft and the monthly sessions of psychotherapy. She was scheduled for the next follow-up visit after four weeks.

 

 Major Depressive Episode

Name: R.D

Age: 45 years

Diagnosis: Major Depressive Epidose

S: R.D is a 45-year-old male that came to the unit for the second follow-up visit after being diagnosed with major depression two months ago. The diagnosis was reached after he experienced symptoms that included a depressed mood most days for every day. He also reported being socially isolated due to a lack of interest in things and pleasure. He found it difficult to engage in social and occupational activities due to his depressed mood. The client’s ability to make informed decisions was also affected. As a result, the client was diagnosed with major depression and initiated on psychotherapy and antidepressants.

O: The client appeared appropriately dressed for the occasion. His self-reported mood was ‘improved.’ The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and suicidal plans.

A: The symptoms of depression have improved. The client tolerates the treatment.

P: The client was advised to continue with the current treatment. He was also advised to come for a follow-up visit after four weeks.

 

Insomnia

Name: E.D

Age: 35 years

Diagnosis: Insomnia

S: E.D is a 35-year-old male who came to the clinic for his seventh follow-up visit for insomnia. He was diagnosed with insomnia after presenting to the unit with complaints of difficulties falling asleep and maintaining sleep. He also reported increased episodes of night awakenings and finding it hard to sleep afterward. There were also complaints of reduced energy levels and a decline in overall performance and productivity. The sleep difficulties could not be attributed to any medical condition, medication, or substance abuse. As a result, E.D was diagnosed with insomnia and initiated on group psychotherapy sessions in the unit.

O: The client appeared appropriately dressed for the occasion. His orientation to self, place, time, and events were intact. The self-reported mood of the client was normal. The judgment of the client was intact. He denied any history of delusions, hallucinations, or illusions. He also denied any history of suicidal thoughts, attempts, and plans.

A: Group psychotherapy sessions have effectively improved the client’s quality and quantity of sleep.

P: Group psychotherapy sessions were terminated after consent was obtained from the client. The treatment objectives had been achieved.

 

Generalized Anxiety Disorder

Name: D.A

Age: 32 years

Diagnosis: Generalized anxiety disorder

S: D.A. is a 32-year-old female who came to the unit for her sixth follow-up visit for generalized anxiety disorder. She was diagnosed with the disorder after presenting with excessive fear and worried about the unknown. She reported experiencing intensive anxiety and fear of things for more than three months before the visit to the unit. She found it difficult to concentrate due to excessive fear. The additional assessment showed that the excessive fear and anxiety could not be attributed to any cause such as medical condition, medication, or substance use and abuse. As a result, she was diagnosed with generalized anxiety disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. She was oriented to place, time, and self. The speech rate and volume were normal. The self-reported mood was normal. The client denied any history of hallucinations, delusions, or illusions. The memory of the client was intact.

A: The client has developed effective coping against excessive worry and anxiety. She has demonstrated continuous improvement in performance and management of precipitating factors.

P: The client’s participation in the group psychotherapy sessions was terminated. The treatment objectives had been achieved.

 

Panic Disorder

Name: Y.Y

Age: 20 years

Diagnosis: Panic Disorder

S: Y.Y is a 20-year old student that came to the unit for a monthly visit after being diagnosed with panic disorder five months ago. Y.Y. has been on group psychotherapy sessions. Y.Y was diagnosed with panic disorder after she presented with complaints that included unexpected panic attacks. The accompanying symptoms included intense fear of unknown attacks in the future, palpitations, sweating, shaking, feeling choked, chest pains, and avoidance of stimuli or conditions associated with the panic attacks. A further assessment established that the attacks were not attributable to causes such as substance abuse, medical condition, or medication use. As a result, she was diagnosed with panic disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, and time. Her judgment was intact. The mood was normal. The speech had a normal rate, speed, and volume. The client demonstrated the development of adequate coping skills with panic attacks. She denied any recent history of hallucinations, illusions, or delusions.

A: The client has developed effective coping skills against panic attacks. Episodes of panic attacks have also reduced significantly.

P: Cognitive behavioral therapy is effective in symptom management. The client was advised to continue with the treatment and scheduled a follow-up visit after four weeks.

 

Substance Use Disorder

Name: B.B

Age: 38 years

Diagnosis: Substance use disorder

S: B.B is a 38-year-old client who came to the unit for his fourth follow-up visit after being diagnosed with alcohol use disorder three months ago. He has been on pharmacological treatment and group psychotherapy. The diagnosis was reached after B.B came to the unit with complaints of persistent consumption of larger amounts of alcohol for one year. He also reported being unsuccessful in stopping binge alcohol consumption due to withdrawal symptoms. B.B was worried that he had been engaging in activities, including selling his property to get money for alcohol. As a result, the socioeconomic status of his family had declined significantly. Alcohol addiction had caused a significant decline in his social and occupational productivity. Therefore, he was diagnosed with substance use disorder and initiated on treatment.

O: The client was well-groomed for the occasion. His orientation to self, others, time, and events were intact. His participation in group psychotherapy was effective in reducing his alcohol cravings. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.

A: The client is responding well to the adopted treatments.

P: The client was advised to continue with the current treatment approaches. He was scheduled for a follow-up visit after four weeks.

 

Bipolar Disorder

Name: R.E

Age: 38 years

Diagnosis: Bipolar Disorder

S: R.E is a 28-year-old client that came to the unit for her follow-up after she was diagnosed with bipolar disorder three months ago. The diagnosis was reached after she came to the unit with complaints of elevated and depressed mood episodes. Symptoms including participating in goal-oriented activities and delusions were experienced during periods of elevated mood. The symptoms alternated with depression, such as insomnia, lack of energy, feelings of guilt, and difficulties in concentrating and making decisions. The alternation of symptoms lasted for a month. The client was worried that the symptoms had significantly affected her ability to engage in her daily routines. Further assessment ruled out drug use, medical problem, or substance and alcohol abuse as the cause of the problem. As a result, she was diagnosed with bipolar disorder and initiated on treatment.

O: The client appeared appropriately dressed for the occasion. She was oriented to self, place, time, and events. Her judgment was intact. She denied any recent experience of delusions, hallucinations, illusions, suicidal thoughts, plans, and attempts.

A: The adopted treatments are effective, as evidenced by improvement in symptoms. The client tolerates the treatment well.

P:  The client was advised to continue with the treatments. She was booked for a follow-up visit after four weeks.