Assignment 1: Clinical Hour and Patient Logs PRAC 6665

Assignment 1: Clinical Hour and Patient Logs PRAC 6665

Clinical Logs

Major Depression

Name: E.T

Age: 44 years

Diagnosis: Major Depression

S: E.T is a 44-year-old client that came to the unit for his follow-up visit after being diagnosed with depression two months ago. The diagnosis was reached after he presented initially with complaints of a suicide attempt. E.T. wanted to kill himself, as he felt useless. He also reported excessive feelings of guilt. E.T also reported a history of depressed mood for most of the days which made it hard for him to engage in his activities of daily living. The client’s interest in pleasure had also declined significantly. He appeared fatigued most of the days and found it hard in making decisions. There was also the complaint of the lack of appetite. The client reported suicidal thoughts and attempts. He denied any current suicidal plans. Consequently, he was diagnosed with depression and initiated on treatment.

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O: The client appeared well dressed for the occasion. He reported that his mood was improved. The client was oriented to self, others, time, and events. He denied illusions, delusions, and hallucinations. He denied suicidal thoughts, attempts, and current suicidal plans. His speech was normal in terms of rate and volume.

A: The client is responding well to treatment. He does not report any adverse effects.

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

Major Depression

Name: X.V

Age: 38 years

Diagnosis: Major depression

S: X.V is a 38-year-old client that came to the unit for his fourth follow-up visit for major depression.  He has been on antidepressants and psychotherapy treatments. The diagnosis of major depression was reached after the client presented with symptoms that included persistent feelings of guilt and worthlessness. He reported feeling sad on most days almost throughout the day. He noted that his mood was depressed most of the time. There was also the complaint of a decline in his appetite and consistently low energy levels. He denied suicidal thoughts, plans, or attempts. The above complaints led to him being diagnosed with major depression and have been undergoing treatment in the unit.

O: The client was dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His self-reported mood was normal. His speech was normal in terms of rate and volume. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, attempts, and plans.

A: The client is responding well to the treatment, as the symptoms of major depression have improved as expected in the treatment plan.

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

Major Depression

Name: A.A

Age: 27 years

Diagnosis: Major Depression

S: A.A. is a 27-year old client brought today to the unit with a history of a suicidal attempt. The client had attempted to commit suicide by drinking an organophosphate. The client reported that he wanted to kill himself because he always felt hopeless. The family reported that the client was socially withdrawn. He did not have an interest in pleasure. He also gets easily irritated with things. The client reported that his energy levels were low on most of the days. He denied his current suicidal plan. He however has a suicidal attempt. Due to the above complaints, the client was diagnosed with major depression and initiated treatment.

O: The client appears poorly groomed for the occasion. He maintains minimal eye contact during the assessment. His orientation to self, others, place, time, and events was intact. He denied hallucinations, illusions, and delusions. His speech was normal in rate and volume. He reported recurrent suicidal thoughts with one attempt. He does not have any current suicidal plans. His judgment is intact.

A: The client is experiencing severe symptoms of depression and is at risk of self-harm

P: The client was admitted for inpatient monitoring. He was prescribed antidepressants. He would be initiated on psychotherapy once stabilized.

Post-Traumatic Stress Disorder

Name: G.L

Age: 34 years

Diagnosis: Post-traumatic stress disorder

S: G.L is a 34-year-old female client who came to the unit today for her regular follow-up visits for post-traumatic stress disorder. She was diagnosed with the disorder five months ago and has been undergoing treatment. She reported that her mental health problems began after being involved in a road accident. She came initially to the unit with complaints of flashbacks and nightmares about the accident. She also avoided any stimuli that related to the accident. G.L. further reported being easily irritated, experiencing difficulties in sleeping and concentration. Therefore, her family brought her to the unit where she was diagnosed with post-traumatic stress disorder and initiated on treatment.

O: The client was well-groomed for the occasion. Her orientation to self, others, environment, and events were intact. Her self-reported mood was normal. Her level of judgment was intact. She denied suicidal thoughts, plans or attempts, illusions, delusions, and hallucinations.

A: The client is responding positively to the treatment. She is also tolerating the medications, as evidenced by the minimal side effects of the antidepressants.

P: The client was advised to continue with the treatments and scheduled for a follow-up visit after one month.

Post-Traumatic Stress Disorder

Name: X.G

Age: 40 years

Diagnosis: Post-traumatic stress disorder

S: X.G. is a 40-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. The diagnosis was reached after he started 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 symptoms 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: X.G. 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 normal. 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.

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

Generalized Anxiety Disorder

Name: R.E

Age: 23 years

Diagnosis: Generalized anxiety disorder

S: R.E is a 23-year old female client that came to the unit for her third follow-up visit after being diagnosed with generalized anxiety disorder four months ago. The diagnosis was reached after she came with complaints of excessive worry and anxiety about unknown outcomes in her life. The feelings were beyond her control. The accompanying symptoms that the client reported included chest pain, shortness of breath, and sweating. The symptoms could not be attributed to other causes such as medication use, substance abuse, and medical conditions. As a result, she was diagnosed with generalized anxiety disorder and initiated on individual psychotherapy.

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

A: The individual psychotherapy treatment has been effective, as evidenced by improvement in symptoms.

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

Obsessive-Compulsive Disorder

Name: R.V

Age: 25 years

Diagnosis: Obsessive-compulsive disorder

S: R.V. is a 25-year-old male who came to the clinic for his third follow-up visit after being diagnosed with obsessive-compulsive disorder. He was diagnosed with the disorder after presenting with complaints that included frequent experiences of persistent and recurrent intrusive and unwanted urges. The symptoms were associated with considerable anxiety and distress, as he found it hard suppressing them. The compulsive behaviors included checking, which is time-consuming. The symptoms could not be attributed to other causes such as medication, medication, substance abuse, or medical condition. Therefore, he was diagnosed with obsessive-compulsive disorder and initiated on psychotherapy.

O: The client appeared well-groomed for the occasion. His orientation of the client to self, others, events, and time were intact. The mood was normal. Thought content and process were intact. He denied illusions, delusions, and hallucinations. He also denied suicidal thoughts, plans, and attempts.

A: There has been improvement in the symptoms of obsessive-compulsive disorder.

P: The client was advised to continue with psychotherapy sessions. He was scheduled for a follow-up after one month.

Insomnia

Name: H.O

Age: 30 years

Diagnosis: Insomnia

S: H.O is a 30-year-old male who came to the clinic for his fifth follow-up visit after being diagnosed with insomnia. He has been on group psychotherapy sessions to help him manage his problem. He was diagnosed with insomnia after he presented to the unit with complaints of difficulties in falling asleep and maintaining sleep. He also reported sleeping during the day due to the lack of enough sleep at night. His energy levels during the day were significantly reduced. As a result, he was worried that his productivity was not at the expected level. The client could not attribute the symptoms to any cause such as medical condition, medications, or substance abuse. Due to the above complaints, he was diagnosed with insomnia and has been undergoing 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: The use of group psychotherapy treatment has been effective in managing the symptoms of insomnia.

P: The decision to terminate the client’s participation in psychotherapy sessions was made. The treatment outcomes had been achieved.

Bipolar Disorder

Name: J.P

Age: 44 years

Diagnosis: Bipolar Disorder

S: J.P is a 44-year-old client that came to the unit for his follow-up visit after being diagnosed with bipolar disorder five months ago. The diagnosis was reached after she came with complaints that included an expansive mood that was characterized by the patient feeling that he was in control of everything. She was also easily irritable and agitated. She also found it difficult to concentrate on tasks.  She also engaged in goal-directed activities and impulsive behaviors. The above symptoms affected her social and occupational functioning. As a result, she was diagnosed with bipolar disorder and has been on treatment in the unit.

O: The client was dressed appropriately for the occasion. She was oriented to self, time, space, and others. Her judgment was intact. The speech was of normal rate and volume. She denied illusions, delusions, and hallucinations. She also denied suicidal thoughts, attempts, and plans.

A: The desired treatment objectives have been achieved.

P: Psychotherapy sessions were terminated, as the treatment objectives had been achieved. The client was advised to continue with pharmacological treatment. She was scheduled for a follow-up visit after four weeks.

Schizophrenia

Name: R.T.

Age: 26 years

Diagnosis: Schizophrenia

S: R.T is a 26-year-old client that came to the unit for her follow-up visit after being diagnosed with schizophrenia three months ago. The diagnosis was reached after she came with complaints of hearing voices. The client reported that the symptoms had affected severely her level of functioning in areas that included interpersonal relations and work life. The symptoms had persisted for more than five months. The symptoms could not be attributed to other causes such as medication use, medical condition, and substance abuse. As a result, she was diagnosed with schizophrenia and initiated on treatment.

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

A: The client continues to respond positively to the treatment.

P: The client was advised to continue with antipsychotics. She was scheduled for the next follow-up visit in one month.

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Assignment 1: Clinical Hour and Patient Logs

Photo Credit: auremar / Adobe Stock
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 CLIICAL SITE IS A PRIVATE PRACTICE THEY PROVIDE DIRECT CLINICAL SERVICES SUCH AS PSYCHIATRIC EVALUATION, CRISIS INTERVENTION, PSYCHOMARMACOLOGY TREATMENTS AND REFERALS AS NECESSARY TO PATIENTS WITH DIFFERENT PSCHYTIATRIC DIAGNOSIS.

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