Discharge Summary and Summary Statement

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Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the "Discharge Summary" template. This discharge summary should address the following:

  1. What behaviors would indicate that the client is sustaining at a healthy baseline?
  2. How would you determine if Eliza met her treatment goals?
  3. What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
  4. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
  5. How would you encourage involvement in community-based resources?

Part 2: Write a 700-1,050-word summary statement about your client, Eliza.

Include or address the following in your summary statement:

  1. Demonstrate whether or not the client met the goals of the treatment plan.
  2. What specifically contributed to the success of the treatment plan or lack thereof?
  3. What language would you use to communicate the outcome to the client?
  4. How would you document the final session?
  5. Include at least three scholarly references in your paper.

Unformatted Attachment Preview

Running head: TREATMENT PLAN REASSESSMENT Treatment Plan Reassessment Carl B. Fletcher Grand Canyon University: PCN-610 April 3, 2019 1 TREATMENT PLAN REASSESSMENT 2 Treatment Plan Reassessment A reassessment of the initial treatment plan is warranted due to the follow-up and worsening of the presenting symptoms identified in the initial plan. This reassessment, therefore, is based on the need to assess the effectiveness of the initial treatment plan and revisions to it to ensure a better approach to the presenting problems of the client. The changes are due to ineffective initial treatment planning or execution and hence the need for changes in the plan for more effective approaches to the client. The change in Eliza’s behavior was the continued alcohol consumption which escalated to the point where she was found passed out due to alcohol consumption. The changes in Eliza occurred due to gaps in treatment planning and implementation. The initial treatment plan was designed for anxiety reduction, maintaining abstinence from alcohol, and increasing coping skills. Specifically, the treatment for abstinence was based on the need to identify negative consequences of alcohol and hence maintain abstinence through weekly group therapies. From the changes that have been witnessed since the institution of this program, it seems that the approach did not work to highlight the negative consequences as planned. The changes occurred probably due to the lack of commitment to identifying the negative consequences and learning from them. The initial treatment plan and its components aimed at alcohol abstinence may have been compromised by the level of treatment being inadequate for Eliza’s diagnosis. In the initial treatment, it was identified that Eliza’s alcohol drinking was not a major problem and hence the treatment approach used was to prevent the client from getting into trouble with the administration for bringing alcohol to the dormitory. However, a reassessment of this treatment plan shows that her level of dependence on alcohol may have not been clearly identified. The TREATMENT PLAN REASSESSMENT 3 current state shows that the dependence is higher than earlier predicted and hence a more thorough and focused treatment option is required. The treatment plan will be changed from the current identification of negative consequences to commitment to recovery program. According to Batra et al. (2016), relapses in alcohol abstinence mainly occur due to the lack of further treatment after initial detoxification. Therefore, when using pharmacotherapy as the basis for changing the treatment plan for Eliza, there is the need to initiate a full recovery process which will effectively condition her for life without drugs. This will effectively contribute towards her health. This adjustment will further be accompanied by a reassessment of the other treatment options including anxiety reduction and coping skills. On a secondary level and after the initiation of the recovery program. Eliza will be assessed for effectiveness of the complementing treatment options. The reason for this adjustment in the treatment plan is to adopt a more effective approach to treating Eliza. This is ethical in that it enhances the beneficence of care as one of the principles followed in practice. Additionally, the reassessment allows the counselor to identify their areas of competence and refer the client to the necessary resources for effective treatment. Moreover, the changes to the treatment plan mean one major change will be implemented in the client’s schedule; the move from group therapy to a more committed recovery group based on pharmacotherapy and alcohol recovery treatment. The change identified has been linked to the need to boost the efforts of the treatment plan to implement more thorough and focused treatment of the client when it comes to alcohol abstinence. This will be through pharmacotherapy and recovery therapy commitment. This change means that the resources used with the client will also change. The care accorded to her will also be changed and revved up for better treatment. This will also require an assessment for referral requirements. According to (), TREATMENT PLAN REASSESSMENT 4 the main resource that is checked in making a referral is the human resource and their capability to competently deliver the required service. Therefore, the counselor’s qualifications and experiences running a full recovery program should be assessed. Secondly, the equipment to carry out the treatment should be checked. These include the relevant facilities for the recovery program and the relevant programs for the same. When making the referral, a delicate task is communicating to the client need for referral and how the referral process will work to their advantage. This process is critical because it has to show that the counselor cares for the client and also gain approval from the client. Furthermore, it should protect the client from falling through the cracks and falling out of treatment. Having cultivated a relationship of trust with the client, the counselor has to establish continuity of care and show collaboration with referral parties so as to not only maintain the client’s confidence but also ensure effectiveness in maintaining treatment (Levy and Williams, 2016). The best approach is maintaining the confidentiality of the client and explaining to them why referral is the best approach. This would be through showing them that referral would improve the treatment and offer a more effective approach. The counselor should thus approach the client and explain the need for referral while showing that they will remain in contact and the counselor will follow closely on her treatment. From the reassessment of the initial treatment plan developed for Eliza, the referral suggested will be mainly to a drug recovery practitioner. This referral is mainly due to the incompetence of the counselor in delivering that focused treatment to the client. This referral will be completed upon further review of the treatment plan for anxiety reduction and coping skills. Furthermore, various instruments may be used for assessing the patient and one such instrument is the Rapid Alcohol Problems Screen (Raps). This instrument is useful in assessing alcohol use TREATMENT PLAN REASSESSMENT 5 disorders meeting the criteria for DSM-5 (Cherpitel and Ye, 2015). Using the assessment tool, the level of alcohol dependence and use disorder can be estimated for proper referral and treatment. The initial treatment plan for Eliza failed due to inadequate treatment approach hence the need for a more rigorous treatment for alcohol dependence. The client’s alcohol use has escalated despite having been placed in therapy to identify the adverse effects of alcohol. This warrants the implementation of a recovery therapy for the client. Referral to professional drug recovery expert will be required to ensure that the client’s needs are effectively met in the treatment. Maintaining contact with and close monitoring of the client’s progress throughout the referral will be crucial for treatment completion. TREATMENT PLAN REASSESSMENT 6 References Batra, A., Müller, C. A., Mann, K., & Heinz, A. (2016). Alcohol Dependence and Harmful Use of Alcohol: Diagnosis and Treatment Options. Deutsches Ärzteblatt International, 113(17), 301. Cherpitel, C. J., & Ye, Y. (2015). Performance of the RAPS4/RAPS4-QF for DSM-5 compared to DSM-IV alcohol use disorders in the general population: Data from the 2000–2010 National Alcohol Surveys. Drug and Alcohol Dependence, 151, 258-261. Levy, S. J., & Williams, J. F. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211. Treatment Plan Based on the information collected in Week 4, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client's strengths and support system in the treatment plan. Client: _Eliza D__________________________ Date: __4/3/2019________ Age:__18___ DOB: __________________ DSM Diagnosis ICD Diagnosis Generalized Anxiety Disorder F41.1 Goals / Objectives: □ Mood Stabilization □ Anxiety Reduction □ Reduce Obsessive Compulsive Behaviors Interventions: Frequency: □ Psychotropic Medication Referral & Consultation □ Journaling □ Weekly □ Bi Weekly □ Monthly □ Cognitive Behavior Therapy □ Skill Training □ other: ____________________ □ Emotion Recognition – Regulation Techniques □ Group □ Individual □ Family □ Psychotropic Medication Referral & Consultation □ Journaling □ Weekly □ Bi Weekly □ Monthly □ Cognitive Behavior Therapy □ Skill Training □ other: ____________________ □ Relaxation Techniques □ Group □ Individual □ Family □ Psychotropic Medication Referral & Consultation □ Journaling □ Weekly □ Bi Weekly □ Monthly □ Cognitive Behavior Therapy □ Skill Training □ other: ____________________ □ Group □ Individual □ Family © 2017. Grand Canyon University. All Rights Reserved. □ Decrease Sensitivity to Trauma Experiences □ Verbalize Memories Triggers &Emotion □ Weekly □ Bi Weekly □ Monthly □ Desensitize Trauma Triggers and Memories □ other: ____________________ □ Utilize Healing Model/Support (Mending the Soul) □ Group □ Individual □ Family □ Establish and Maintain Eating □ Overcome Denial □ Identify Disorder Recovery Negative Consequences □ Maintain Abstinence from substances (Alcohol/Drugs) □ Weekly □ Bi Weekly □ Monthly □ Menu Planning □ Nutrition Counseling □ Body Image Work □ other: ____________________ □ Healthy Exercise □ Trigger Mngmt Recovery Plan □ CBT □ Group □ Individual □ Family □ Substance Use Assessment □ Stepwork □ Overcome Denial □ Identify Negative Consequences □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Increase Coping Skills □ DBT Skills Training □ Problem Solving Techniques □ Weekly □ Bi Weekly □ Monthly □ Emotion Recognition & Regulation □ Communication Skills □ other: ____________________ □ Group □ Individual □ Family □ Stabilize, Adjustment to New Life Circumstances □ Alleviate Distress Behavior Therapy □ Cognitive □ Weekly □ Bi Weekly □ Monthly □ Stress Management □ Skills Training □ other: ____________________ □ Improve Daily Functioning □ Develop Healthy Support □ Group □ Individual □ Family © 2017. Grand Canyon University. All Rights Reserved. □ Decrease/Eliminate Self Harmful Behaviors □ Cognitive Behavior Therapy □ Skills Training □ Weekly □ Bi Weekly □ Monthly □ Develop and Utilize Support System □ other: ____________________ □ Group □ Individual □ Family □ Improve Relationships □ Communication Skills □ Active Listening □ Family Therapy □ Assertiveness □ Setting Healthy Boundaries □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Improve Self Worth □ Affirmation Work □ Positive Self Talk □ Skills Training □ Weekly □ Bi Weekly □ Monthly □ Confidence Building Tasks □ other: ____________________ □ Group □ Individual □ Family □ Grief Reduction and Healing from Loss □ Develop Anger Management Skills □ Psychoeducation on Grief Process/ Stages □ Weekly □ Bi Weekly □ Monthly □ Process Feeling □ Emotion Regulation Techniques □ other: ____________________ □ Reading/Writing Assignments □ Develop/Utilize Support □ Group □ Individual □ Family □ Decrease Anger Outbursts □ Emotion Regulation Techniques □ Cognitive Behavior Therapy □ Weekly □ Bi Weekly □ Monthly □ Increase Awareness/Self Control □ other: ____________________ □ Group □ Individual □ Family © 2017. Grand Canyon University. All Rights Reserved. Topic 8 Discharge Summary Template Directions: Complete the Discharge Summary form by addressing the fields below. Client Name: [Enter the client's name here] Date of Birth: [MM/DD/YYYY] Date of Admission: [MM/DD/YYYY] Date of Discharge: [MM/DD/YYYY] Presenting Problem Upon Admission: [State the client's presenting problem upon admission here.] Current Medication: [List the client's current medications here.] Reason for Discharge: [State the client's reason for discharge here.] Resources and Referrals: [List the client's resources and referrals here.] © 2017. Grand Canyon University. All Rights Reserved. Projected Prognosis: [State the client's projected prognosis here.] Eliza D 00/00/00 Client Signature & Date Case Manager Signature & Date © 2017. Grand Canyon University. All Rights Reserved.
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Explanation & Answer

Attached.

Running head: CLIENT SUMMARY STATEMENT

Client Summary Statement
Name
Institution Affiliation
Date

1

CLIENT SUMMARY STATEMENT

2
Goals of Treatment

The client in question Ms. Eliza did not meet the goals of the treatment plan. The main
reason as to why there is a reassessment is as a result of the differences that emerged between
what was intended to be achieved and what was achieved. Based on the follow-up, there is a
significant discrepancy between what could have been achieved and what was achieved. In
presenting the reassessment plan, the aim is to help the patient walk towards the journey of full
recovery. In the example, the change in the behavior of the client is believed to be as a result of
continuous consumption of alcohol and the plan was not fully effective to cover this. A robust
and comprehensive plan should not only help in the rehabilitation process but also in assisting
the client in abstaining completely. The second loophole in the treatment plan was the gaps that
were experienced in treatment planning and implementation. In the first instance, the treatment
plan was designed to help the client reduce her anxiety, maintain abstinence from alcohol and
help them increase their coping skills.
The negative needs of alcohol were identified, but a commitment to the recovery program
was not made compulsory for the client and this signi...

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