PCN 610 Discharge Summary and Summary Statement Assignment

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:

What behaviors would indicate that the client is sustaining at a healthy baseline?
How would you determine if Eliza met her treatment goals?
What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
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). PCN 610 Discharge Summary and Summary Statement Assignment
How would you encourage involvement in community-based resources?

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

Include or address the following in your summary statement:

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

Submit your discharge summary and summary statement to your instructor.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

This assignment meets the following CACREP Standard: 2.F.5.k: Strategies to promote client understanding of and access to a variety of community-based resources intervention.

This assignment meets the following NASAC Standards:

73) Conduct continuing care, relapse prevention, and discharge planning with the client and involved significant others.

74) Assure the accurate documentation of case management activities throughout the course of treatment.

75) Apply placement, continued stay, and discharge criteria for each modality on the continuum of care.

112) Prepare and record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.

114) Prepare an accurate, concise, informative, and current discharge summary.

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]

Eliza D 00/00/00		<sign and date here>
Client Signature & Date		Case Manager Signature & Date

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. PCN 610 Discharge Summary and Summary Statement Assignment

Client: ____________________________________________ Date: ______________ Age:______ DOB: __________________

DSM Diagnosis	ICD Diagnosis

Goals / Objectives:

Interventions:

Frequency:

□ Mood Stabilization

□ Psychotropic Medication Referral & Consultation □ Journaling

□ Cognitive Behavior Therapy □ Skill Training

□ Emotion Recognition – Regulation Techniques

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Anxiety Reduction

□ Psychotropic Medication Referral & Consultation □ Journaling

□ Cognitive Behavior Therapy □ Skill Training

□ Relaxation Techniques

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Reduce Obsessive Compulsive Behaviors

□ Psychotropic Medication Referral & Consultation □ Journaling

□ Cognitive Behavior Therapy □ Skill Training

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Decrease Sensitivity to Trauma Experiences

□ Verbalize Memories Triggers & Emotion

□ Desensitize Trauma Triggers and Memories

□ Utilize Healing Model/Support (Mending the Soul)

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Establish and Maintain Eating Disorder Recovery

□ Overcome Denial □ Identify Negative Consequences

□ Menu Planning □ Nutrition Counseling □ Body Image Work

□ Healthy Exercise □ Trigger Mngmt Recovery Plan □ CBT

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Maintain Abstinence from substances (Alcohol/Drugs)

□ 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

□ Emotion Recognition & Regulation □ Communication Skills

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Stabilize, Adjustment to New Life Circumstances

□ Alleviate Distress □ Cognitive Behavior Therapy

□ Stress Management □ Skills Training

□ Improve Daily Functioning □ Develop Healthy Support

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Decrease/Eliminate Self Harmful Behaviors

□ Cognitive Behavior Therapy □ Skills Training

□ Develop and Utilize Support System

□ Weekly □ Bi Weekly □ Monthly

□ 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

□ Confidence Building Tasks

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Grief Reduction and Healing from Loss

□ Psychoeducation on Grief Process/ Stages

□ Process Feeling □ Emotion Regulation Techniques

□ Reading/Writing Assignments □ Develop/Utilize Support

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

□ Develop Anger Management Skills

□ Decrease Anger Outbursts □ Emotion Regulation Techniques □ Cognitive Behavior Therapy

□ Increase Awareness/Self Control

□ Weekly □ Bi Weekly □ Monthly

□ other: ____________________

□ Group □ Individual □ Family

Eliza Treatment Plan Sample

Part 1

The answer that Eliza gives on the intake document calls for being explored as much as possible. I would precisely ask Eliza to tell me her feeling about the as to why she is stressed and in case she encountered the very sort stress before she came to college (Carlson, 2017). One very important thing to discuss is the feeling of Eliza about herself so that you can be in a position to help her with her self-esteem. It is essential to know and tell if she ever struggled with the situation of low self-confidence before she came to college or find out if she started feeling this way when she came to college. Details on how she responds the status of between her and her parents are also needed. What I would like is an explanation of what her parents mean as well as her feeling on how the relationship can be improved and in case the relationship was any better or worse at any given point. I would also like to know if she maintains the relationship with her old friends in high school and how frequent she visits her parents. However, it also of great importance to know is she has joined or has the interest of joining them at the campus. Clubs are a good avenue for meeting new people who have similar interest. An additional issue that ought to be addressed is the reason why a different college from her friends and if she would like to move to college that is closer to home. Her reactions to these key areas will aid in the kind of therapeutic approach that will be successful with her. PCN 610 Discharge Summary and Summary Statement Assignment

Information from her Level 1 Cross-Cutting Measure will pave way to as about things in which she has no interest and those she has no pleasure. I will ask her about situations that stimulate her anxiety, and she has ever gone through anxiety. I will then find out how she deals with anxiety save for situations which make feel anxious. Eliza having reported mild distress sleeping, calls for being explored as it can be connected to another thing. I will ask her when this frustration in her started and the type of sleep troubles (Suldo, 2016). Eliza’s feeling of failing to know who she wants to be and not knowing who exactly she is not common with people of her age hence worth finding out how long she has been feeling this way. The issue that she does not feel being close to others can originate from the relationship she has with her parents, and this should also be discussed further. I would also like to know if her high school friends go to college that is near her. Eliza’s relationship with her parents together with her issues of self-esteem may be the reason behind her failing to have close connections and badly wants to fit in with her peers.

Part 2

Eliza claims that she is overwhelmed by campus work and confesses that it is difficult to keep up. Adjusting and transitioning to campus has been hard for her, the social element of campus affects Eliza, and it may play a bigger role than she concedes. What makes this stage of Eliza’s life difficult is that her support system is not strong. The alcohol or substance abuse is not the major concern since she uses them to make and fit in new friends. Basing on the issue where she claims to be fine with how she is used by her peers implies that Eliza is desperate when it comes to having friends. She has talked about being tormented while she was in high school which could be connected with her low self-esteem and the desire to have friends. Dwelling on the information that she provided, in addition to the symptoms that she conveyed my diagnosis for Eliza will be the depressive disorder as well as the adjustment disorder. PCN 610 Discharge Summary and Summary Statement Assignment

Eliza can greatly be helped from a Cognitive Behavioral Therapy in the treatment of both adjustment and depressive disorders, with the objective of decreasing her symptoms as well as helping her see herself and the college positively, keeping a record of times that she feels anxious or the time she feel that her peers may be misusing her. The journal will then be gone through during every session so as to expose in patterns and help her in thinking about what she can do contrarily in the situation and how best she can handle the situation in case it occurred in future. One more aim for the treatment will be for her to join a club that interest her in college to meet good people. She will be seen on a weekly basis for an hour over a period of eight weeks. Once this period is over, she can be viewed as needed (Wänke, 2015). Her family can benefit from the program of family counselling which will help in the treatment of strained relationships that they have towards one another. This will also create room for Eliza to honestly tall her parents on how she is fairing on with college.

Part 3

Basing on the information Eliza offered and the diagnosis that was given I will use the Level 2 Depression Cross-Cutting Measure to go on to observe her depression symptoms to decide Eliza’s advancement in treatment. This will also help to see the effectiveness of Cognitive Behavioral Therapy or if it has to be changed. An additional assessment for monitoring her depression symptoms is the Patient Health Questionnaire which asks clients about the level of their symptoms and their regularity. The score which is delivered from the client’s answers will show if the severity of the symptoms is increasing or decreasing. This assessment can be employed during the intake and each session later (Suldo, 2016). It also lets clients see their progress where it was used as a self-reporting assessment. The Patient Health Questionnaire lines up with treatment objectives that will decrease Eliza’s depression symptoms.

References

Carlson, C. (2017). Mental Health. Hauppauge. Hauppauge: Nova Science Publishers, Inc.

Suldo, S. M. (2016). Promoting student happiness: Positive psychology interventions in schools. New York : Guilford Press.

Wänke, M. (2015). Social psychology of consumer behavior. New York : Psychology Press. PCN 610 Discharge Summary and Summary Statement Assignment