PRAC 6645 Assignment 1: Clinical Hour and Patient Logs
PRAC 6645 Assignment 1: Clinical Hour and Patient Logs
PRAC 6645 Clinical Hour and Patient Logs
S: A.L is a 33-year-old client that came to the unit today for his regular follow-up. He was diagnosed with insomnia five months ago and has been on individual psychotherapy. The client recalled that his diagnosis with insomnia was made due to a number of problems that he had been experiencing. They included persistent lack of quality and quantity sleep. The client reported that he found it hard to fall asleep and maintain it. He had used sleep enhancing medications but without any success. The client also reported that he often fell asleep during the day at his workplace due to lack of sleep the previous nights. The lack of quality and quantity sleep was affecting his performance in workplace, as he always felt that he did not have enough energy to undertake his assigned duties. The client denied any history of medical conditions, drug, or substance abuse that could have contributed to the symptoms. As a result, he was diagnosed with insomnia and initiated on individual psychotherapy sessions.
O: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were normal. His judgment was intact. He did not appear tired during the assessment. He maintained normal eye contact. His speech was of normal rate and volume. He denied illusions, hallucinations, and delusions. He also denied suicidal thoughts, attempts and plans.
A: The desired outcomes of treatment have been achieved. The client reports that he no longer experiences insomnia and his functioning has improved tremendously.
P: The individual psychotherapy sessions were terminated with consent from the client. The termination was reached because the treatment goals had been achieved.
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Clinical Hours
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 in order 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.
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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.