Week 9_ patient logs / child – adolescent

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Assignment 9: Clinical Hour and Patient Logs

Assignment Instructions:

· I need

small individual psychotherapy clinical notes (one paragraph), each note should include: CC, small mental status, and progress achieved during the visit. Please review the below example, doesn’t have to exactly as the example but close enough.

· Student 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

· The patient has to be child / adolescent male or female age between 6 to 17, with any (1 or more) of the following diagnosis, please use

the diagnosis listed.

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Male, 17, PTSD, Depressive Disorder, Reactive attachment disorder

A 17-year-old male, diagnosed with PTSD, reactive attachment disorder, and depressive disorder. The patient has come in for his second session accompanied by his foster mother. He is well dressed but looks sad. Patient says, “As a child, I was impulsive and socially disinhibited.” Further, he says, “I was not cared for adequately when I was a child, and I have a history of abuse. I was sexually violated when I was eleven.” His mother died when he was nine years old, and he did not have someone to turn to when his father abused him. He is encouraged to engage more in talk therapy to help him in the treatment this condition. Patient participated in the therapy and engaged in the journal entry activity. Patient will continue the writing exercises outside of therapy for decrease anxiety. The clinician provided support and structure. Psychoeducation was provided regarding medication compliance, and the patient was receptive. The patient has been encouraged to continue with follow-up psychotherapy to help him build healthy emotional skills and reduce problematic patterns of behavior. Individual psychotherapy is scheduled in two weeks to continue improving the patient’s condition.



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