Discharge summary template and summary statement

 

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.

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.

ps please fill out discharge summary template

Discharge Summary Template

Directions: Complete the Discharge Summary form by addressing the fields below.

Client Name: Date of Birth:

Date of Admission: Date of Discharge:

Presenting Problem Upon Admission:

Current Medication:

Reason for Discharge:

Case Manager Follow Up:

Resources & Referrals:

Eliza D 00/00/00

Client Signature & Date

Case Manager Signature & Date

© 2015. Grand Canyon University. All Rights Reserved.

© 2015. Grand Canyon University. All Rights Reserved.

Running head: TREATMENT PLAN REFLECTION

1

TREATMENT PLAN REFLECTION

7

Treatment Plan Reflection

Name: Katrina Colon

Grand Canyon University

Treatment Plan Reflection

Introduction

From the treatment plan provided, it is evident that Eliza suffers from mental disorders which have resulted from depression. The DSM diagnosis reveals that the disorders were as a result of isolation and anger that made Eliza turn to alcohol. The goals of the treatment to reduce this condition include mood stabilization, reducing obsessive and compulsive behaviors, decreasing sensitivity to human trauma experiences and reducing anxiety. Also, they include maintaining and establishing sleeping and eating disorder recovery, increasing coping mechanisms, abstinence from drug and alcohol substances as well as enhancing increasing coping skills.

Why the changes occurred

The changes happened on Eliza because of depression and stress. Depression is defined as a condition of low mood and dislike of activity. It may develop as a normal response to happening life events or incidents, a sign of a medical state or the result of side effects of drugs or medicinal treatment(Greenberg, 2017). Depression can also develop as a sign of specific psychiatric syndromes, for example the mood disorder major depressive disorder and dysthymia. these were the signs that ere being observed from Eliza. Young people show signs of increased bad temper or violent or self-destructive manners as opposed to the general sadness adult people express in depression. Most depressions are co-morbid with mental disorders independent of other mood disorders, most frequently anxiety disorder and conduct disorder. Depression also tends to run in some family lines(Harbeler, 2017). Psychologists have come up with different treatment methods to help children and adolescents who suffer from depression. However, the authenticity of the analysis of childhood depression as psychiatric condition together with the effectiveness of various methods of assessment and treatment employed remains a controversial issue.

The effectiveness and Validity of the Treatment plan

The treatment plan was effective in enabling the patient, Eliza to improve before taking her through a rehabilitation and clinical treatment that could improve her to the initial normal state. The treatment plan seeks to identify the negative effects of her habits and make the required improvement changes and suggestions to correct them. For instance, Eliza will be encouraged to be social and interact more with people and to improve her health, she will be required to identify negative consequences of her eating habits, reduce fat content in her diet, administer more fluids and vitamins as well as ensure Eliza sleeps in time and wakes up in time.

How the treatment plan needs to be adjusted to address the changes in the situation

There are multiple methods of treating depression. The most commonly used treatment methods are psychotherapy and medications. Some depression patients prefer psychotherapy to antidepressant medication for treatment. In children, antidepressants use is often viewed as the last option (Harbeler, 2017). Nevertheless, studies have shown that combining psychotherapy and medication proves the most effective form of treatment. Treatment programs have been created that aid in reducing effects of depression.

Various types of therapy used in treating depression. Firstly, talk therapy that helps people to live fuller and better lives. Secondly, cognitive therapy that tries to change a person’s harmful and negative thoughts using positive ways. Behavioral therapy on the other hand helps in changing one’s harmful ways of acting so that they can be able to control that behavior. Another form of therapy, interpersonal therapy, helps individuals to improve their relations with others by expressing feelings and development of improved social skills. Psychotherapy teaches teens skills to cope while at the same time allowing them to explore their feelings and various events in safe surroundings. The last type of therapy is family therapy. This involves the participation of the whole family with a family therapist. To sum everything up, regardless of a person’s choice of treatment, early diagnosis of depression symptoms is important in order to root it out early.

Justifying the changes

People’s appearances on the outside always show the sudden change of our physical bodies from just infants to adult people. The changes that come with our bodies come in quite dramatic ways. With every stage of development in our lives, new experiences come which trigger various emotional and mental reactions. Studies have been conducted to show how depression emerges in an individual, how it develops and how it affects an individual over the years (Wasserman, 2011). Therefore, for Eliza to return to her normal state the changes are necessary and should be administered.

What the changes (obstacles) mean to the treatment plan

The changes are important because they will improve the treatment plan. Depression in children and adolescents is like that of an adult major depressive disorder. However, younger people show signs of increased lousy temper or violent or self-destructive manners as opposed to the general sadness adult people express in depression. Children who suffer stress, show anxiety disorders, loss of learning, attention or behavioral methods are at a higher risk of depression. Most childhood depressions are co-morbid with mental disorders independent of other mood disorders, most frequently anxiety disorder and conduct disorder (Greenberg, 2017). Depression also tends to run in some family lines. Psychologists have come up with different treatment methods to help children and adolescents who suffer from depression. However, the authenticity of the analysis of teenage depression as psychiatric condition together with the effectiveness of various methods of assessment and treatment employed remains a controversial issue. The statistics behind childhood-to-adulthood depression present a vivid picture of how prevalent depression is. About 8% of adolescents and children experience depression.

Discuss how you would evaluate the resources available for you to make a referral.

The resources will be evaluated to determine whether the Eliza needs a referral. If the patient will need support that will not fall within the organizational scope, other alternatives will be investigated to be able to refer Eliza to another service provider (Parkin et al. 2017). There are several essential issues that will be considered when referring a client to another service provider or to another team. This will form part of the treatment plan or the emergency referral. The evaluation will assess whether I will be able to provide the best service possible that will solve the problem of the client. also, the evaluation will assess whether there are specific protocols that should be followed to ensure there is an effective referral process.

Discuss how you would communicate to the client the need for referrals to other providers

Communication is at the center of proper material practice. The General Medical Council has allowed the necessity for excellent communication skills, which calls for patients to be informed of their condition, treatment, investigations, and progress (Dawson, King, & Grantham, 2013). Excellent communication skills are necessary for ensuring the patient care continuity and ensure the safety of patients. The shift system introduction has made an efficient communication to be more critical.

Conclusion

To ensure there is effective treatment and diagnosis of the existing causes of mental disorders and depression as well as other causes of the problems faced by Eliza, the prescription will require the patient to take or institute secondary preventive measures because it may be possible she has depression. The aim of this step is to ensure quick progression of the condition and halting or delaying its progression.

References

Greenberg, L. S. (2017). Emotion-focused therapy of depression. Person-Centered & Experiential Psychotherapies, 1-12.

Haberler, G. (2017). Prosperity and depression: A theoretical analysis of cyclical movements. Routledge.

Parkin, L., Balkwill, A., Sweetland, S., Reeves, G. K., Green, J., Beral, V., & Million Women Study Collaborators. (2017). Antidepressants, Depression, and Venous Thromboembolism Risk: Large Prospective Study of UK Women. Journal of the American Heart Association, 6(5), e005316.

Wasserman, D. (2011). Depression (2nd ed.). Oxford: Oxford University Press.