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In this assignment, you will complete psychotherapy counseling note of an adult/older adult. You can use a patient you’ve seen in clinical or someone in your personal life. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point.
At a minimum, 4 scholarly references should be included and cited in APA 7th Edition formatting. The references page should be set up similar to papers that are in full APA 7th edition formatting.
Here is the rubric for grading:
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Subjective Data

25 pts
Exemplary Exceeds Expectations
Client description was 1-2 sentences in length. Includes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in systematic, organized manner consistently.

20 pts
Advanced Meets Expectations
Includes most subjective data with omission of two minor details or one major detail. Most data is presented in systematic, organized manner.

15 pts
Intermediate Needs Improvement
Includes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.

10 pts
Novice Inadequate
Data is not presented in a systematic, organized manner. Lacking most or all subjective data.

0 pts
Incomplete
Assignment not completed or submitted late.

25 pts
This criterion is linked to a Learning Outcome Objective Data

25 pts
Exemplary Exceeds Expectations
Client description was 1-2 sentences in length. Includes all relevant subjective data necessary for differentiation of the client’s problem using the OLDCART and/or SIGECAPS Mnemonics.

20 pts
Advanced Meets Expectations
Objective data is complete and presented in an organized manner most of the time. Appearance, behavior, eye contact, speech, mood, affect, thought process, thought content, perceptual abnormalities, cognition, orientation, memory, insight, and judgment are addressed and 1-2 are missing.

15 pts
Intermediate Needs Improvement
Objective data is not complete or is not presented in an organized manner. Appearance, behavior, eye contact, speech, mood, affect, thought process, thought content, perceptual abnormalities, cognition, orientation, memory, insight, and judgment are addressed and 3 or more are missing.

10 pts
Novice Inadequate
Objective data is not complete and is not presented in an organized manner. Lacking most or all objective data.

0 pts
Incomplete
Assignment not completed or submitted late.

25 pts
This criterion is linked to a Learning Outcome Assessment

25 pts
Exemplary Exceeds Expectations
Assessment, includes progress note- 5 or more sentences, or notation that it is not applicable as it is an initial visit, Diagnosis-current and rule-out, Homework: 2-3 sentences with plan or notation why it is not applicable to this client, need for follow up, CPT code that is applicable for session that are complete and appropriate to client. ICD code that is applicable for session is complete and appropriate for session.

20 pts
Advanced Meets Expectations
Assessment, includes progress note- minimal 2-5 sentences or notation that it is not applicable as it is an initial visit, Diagnosis- current and rule-out, Homework 1-2 sentences with plan or notation why it is not applicable to this client, need for follow up, CPT code, but some of the content is not appropriate for client. ICD code that is applicable for session is complete and appropriate for session.

15 pts
Intermediate Needs Improvement
Assessment, homework, needs for follow up , CPT code, ICD code, diagnosis (if appropriate), is not complete but is appropriate.

10 pts
Novice Inadequate
Assessment, including diagnosis (if appropriate), is not complete or appropriate, or it is not evident.

0 pts
Incomplete
Assignment not completed. Submits assignment late.

25 pts
This criterion is linked to a Learning Outcome Professional Application

15 pts
Exemplary Exceeds Expectations
Psychotherapy note incorporates four evidence-based practice articles.

10 pts
Advanced Meets Expectations
Psychotherapy note incorporates three evidence-based practice articles.

7 pts
Intermediate Needs Improvement
Psychotherapy note incorporates two evidence-based practice articles.

5 pts
Novice Inadequate
Psychotherapy note Does not include evidence-based practice article but has one advanced practice article or does not include evidence-based practice article or advanced practice article.

0 pts
Incomplete
Assignment not completed.

15 pts
This criterion is linked to a Learning Outcome Organization, APA, Grammar, and Spelling

10 pts
Exemplary Exceeds Expectations
Well organized content that is clear and concise. Correct APA formatting with no errors. The writer correctly identifies reading audience, as demonstrated by appropriate language (avoids jargon and simplifies complex concepts appropriately). There are no spelling, punctuation, or word-usage errors.

8 pts
Advanced Meets Expectations
Organized content that is informative and supportive of purpose. Correct and consistent APA formatting of references, and cites all references used. No more than one to two unique APA errors. There are minimal to no grammar, punctuation, or word-usage errors.

7 pts
Intermediate Needs Improvement
Poor organization and flow of ideas may distract from the content. Three to four unique APA formatting errors. The writer occasionally uses awkward sentence construction or overuses/inappropriately uses complex sentence structure. Problems with word usage (evidence of incorrect use of thesaurus) and punctuation persist, often causing some difficulties with grammar. Some words, transitional phrases, and conjunctions are overused. Multiple grammar, punctuation, or word usage errors.

6 pts
Novice Inadequate
Illogical flow of ideas. Many APA formatting errors, or no attempt to format in APA. The writer struggles with limited vocabulary and has difficulty conveying meaning–noting just the broadest of meanings. Grammar and punctuation are consistently incorrect. Spelling errors are numerous. Submits assignment late.

0 pts
Incomplete
Assignment not completed.

10 pts
Total Points: 100

 

 

To complete the psychotherapy counseling note for an adult/older adult in this assignment, the following structure should be followed to ensure a comprehensive assessment and meet the grading rubric requirements:

1. Subjective Data (25 points)

The subjective data should provide a clear and organized description of the client’s concerns. It should include the client’s personal account of their emotional, psychological, and physical state.

• Client’s Description: Provide a brief summary of the client’s situation (e.g., “Client is a 58-year-old woman seeking therapy for ongoing feelings of sadness and isolation after the recent death of her spouse.”)
• Presenting Problem: Detail the client’s reason for seeking therapy, which could include emotional distress, life changes, or mental health symptoms.
• Client’s Feelings/Emotions: Describe the client’s emotional state and how they express their concerns.
• History of Present Illness: Include any relevant background information (e.g., how long the client has been experiencing these symptoms, any previous treatment history, or relevant life events).
• Any Social or Family Context: Note any family dynamics, relationships, or social stressors influencing the client’s state.

2. Objective Data (25 points)

Objective data should provide an observable account of the client’s current physical and mental state, including behaviors and mental status.

• Appearance: Describe the client’s physical appearance (e.g., well-groomed, disheveled).
• Behavior: Note any behavioral observations (e.g., anxious movements, fidgeting, engaging in conversation).
• Eye Contact: Comment on eye contact (e.g., avoids eye contact, maintains steady eye contact).
• Speech: Describe the client’s speech (e.g., slow, pressured, coherent).
• Mood and Affect: Assess mood and affect (e.g., depressed, anxious, flat affect).
• Thought Process and Content: Address the flow of thought (e.g., organized, coherent, tangential).
• Perceptual Abnormalities: If applicable, note any signs of hallucinations or delusions.
• Cognition: Evaluate the client’s memory, orientation, and attention.
• Insight and Judgment: Assess the client’s awareness of their situation and ability to make decisions.
• Risk Assessment: If applicable, assess for risk of harm to self or others (suicidal ideation, homicidal ideation).

3. Assessment (25 points)

The assessment section should include a brief progress note, the client’s diagnosis, and any relevant plans for treatment or follow-up.

• Progress Note: Summarize the current state of the client’s treatment (e.g., “Client reports slight improvement in mood after 3 sessions. However, continued grief and isolation persist.”)
• Diagnosis: Provide the current and potential rule-out diagnosis, ensuring to use appropriate codes (e.g., Major Depressive Disorder – ICD-10 Code F33.1).
• Homework: If relevant, suggest any homework for the client to complete (e.g., journaling emotions or practicing mindfulness).
• Need for Follow-Up: Indicate the need for continued sessions and the frequency (e.g., “Follow-up in one week to assess progress and discuss coping strategies.”)
• CPT Code: Include the appropriate Current Procedural Terminology code for the session (e.g., 90837 for psychotherapy).
• ICD Code: Ensure the correct ICD code is included for diagnosis and session appropriateness.

4. Professional Application (15 points)

In this section, provide references to at least four evidence-based practice articles that support your approach to the therapy, diagnosis, and treatment plan for the client.

• Incorporate Evidence-Based Practice: Use four scholarly references to inform your psychotherapy process. For example, references may include studies on the effectiveness of cognitive-behavioral therapy for depression or grief, or research on assessing and treating elderly clients with mental health disorders.
• Evidence-based Articles: These can include articles on psychological assessments, treatment methodologies, and therapeutic approaches for similar cases.

5. Organization, APA, Grammar, and Spelling (10 points)

• Organization: Ensure the note is well-organized and written clearly, with each section labeled appropriately.
• APA Formatting: Follow the APA 7th Edition guidelines, including appropriate citation of sources and formatting of the reference page.
• Grammar and Spelling: Ensure that the note is free from grammatical or spelling errors. Proofread your work before submission to check for clarity and readability.

Example of APA-Formatted Reference List:

• Brown, T., & Green, M. (2021). The efficacy of cognitive-behavioral therapy for grief and loss in older adults. Journal of Clinical Psychology, 67(3), 120-134. https://doi.org/10.1037/cli0000342
• Dellinger, R. B. (2020). Grief and mental health: A review of interventions for older adults. Aging & Mental Health, 24(2), 211-218. https://doi.org/10.1080/13607863.2019.1586046
• Harlow, R., & Turner, L. (2019). Addressing depression in older adults: Evidence-based practices. Journal of Psychiatric Practice, 25(1), 45-53. https://doi.org/10.1097/01.pra.0000574845.54579.56
• Williams, K. (2020). Therapy approaches in treating older adult depression: A meta-analysis. American Journal of Therapy, 22(4), 211-223. https://doi.org/10.1016/j.therapy.2020.03.011

By structuring your psychotherapy note following these criteria and referencing relevant scholarly articles, you will provide a detailed, well-supported report for the assignment.

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