The Veterans and Active Duty Military Psychotherapy Progress Notes Planner

Arthur E. Jongsma, Jr., David J. Berghuis

• Publisher: Wiley
• Year: 2010
• Print ISBN: 9780470440971
• eBook ISBN: 9780470586075
• Edition: 1
• Topic: Psychology
• Subtopic: Research & Methodology in Psychology
• Index: Psychology

The Veterans and Active Duty Military Psychotherapy Progress Notes Planner contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Veterans and Active Duty Military Psychotherapy Treatment Planner. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation.

• Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes
  
  

• Organized around 39 behaviorally based presenting problems, including nightmares, post- deployment reintegration, combat and operational stress reaction, amputation and/or loss of mobility, adjustment to killing, and depression
  
  

• Features over 1, 000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered)
  
  

• Provides an array of treatment approaches that correspond with the behavioral problems and DSM-IV-TR diagnostic categories in The Veterans and Active Duty Military Psychotherapy Treatment Planner
  
  

• Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA
  
  

• Presents new and updated information on the role of evidence-based practice in progress notes writing and the special status of progress notes under HIPAA
  
  

TOBACCO USE

VETERAN/SERVICE MEMBER PRESENTATION

1. Consistent Tobacco Use (1)⁷⁵

a. The veteran/service member described a history of consistent tobacco use manifested by increased use, tolerance, and withdrawal.

b. The veteran/service member acknowledged that he/she has consistently used tobacco, with an inability to successfully discontinue use.

c. The veteran/service member has committed himself/herself to a plan of abstinence from tobacco use.

d. The veteran/service member has maintained total abstinence from nicotine use, which is confirmed by others.

2. Exhibits Decreased Physical Fitness (2)

a. The veteran/service member acknowledged that he/she has become less physically fit because of his/her use of tobacco.

b. The veteran/service member displayed physical indicators that reflect the results of heavy tobacco use (e.g., decreased lung capacity, decreased stamina).

c. The veteran/service member acknowledged that his/her physical problems are related to his/her pattern of heavy tobacco use.

d. As the veteran/service member has participated in the recovery program and has been able to maintain abstinence from tobacco, his/her physical status has improved.

3. Increased Tobacco Use (3)

a. The veteran’s/service member’s frequency of tobacco use is increasing.

b. Despite the veteran’s/service member’s attempts at decreasing tobacco use, he/she has continued to increase tobacco use.

4. Inability to Terminate or Reduce Tobacco Use (4)

a. The veteran/service member acknowledged that he/she frequently has attempted to terminate or reduce use of tobacco but found that he/she has been unable to follow through.

b. The veteran/service member acknowledged that, in spite of negative consequences and a desire to terminate tobacco use, he/she has been unable to do so.

c. As the veteran/service member has participated in a total recovery program, he/she has been able to maintain abstinence from nicotine.

5. Physical Withdrawal Symptoms (5)

a. The veteran/service member acknowledged that he/she has experienced physical withdrawal symptoms (e.g., tobacco craving, anxiety, insomnia, irritability, depression) when going without nicotine for any length of time.

b. The veteran’s/service member’s physical symptoms of withdrawal have eased as he/she has stabilized in maintaining abstinence from tobacco products.

6. Social Dissatisfaction Due to Tobacco Use (6)

a. The veteran/service member complained of discolored teeth, bad breath, and/or foul-smelling clothes due to tobacco use.

b. The veteran/service member identified significant social dissatisfaction and alienation due to the personal hygiene effects of his/her tobacco use.

c. As the veteran’s/service member’s tobacco use has decreased, his/her personal hygiene has improved, along with his/her social satisfaction.

7. Intense Cravings (7)

a. The veteran/service member identified intense nicotine cravings after awakening in the morning.

b. The veteran/service member reported intense nicotine cravings when he/she is unable to use tobacco for several hours at a time.

c. The veteran/service member reported that his/her performance has been affected by his/her intense cravings for nicotine.

d. As the veteran’s/service member’s tobacco use has decreased, his/her nicotine cravings have gradually decreased as well.

8. Lying (8)

a. The veteran/service member has lied to family and/or friends in order to hide his/her tobacco use.

b. The veteran/service member reports a sense of guilt for his/her untruthfulness to family and friends regarding tobacco use.

c. The veteran/service member has become more honest about his/her tobacco use.

9. Tobacco Use Despite Losses (9)

a. The veteran/service member has continued to use tobacco despite having someone close die from tobacco-related cancer or pulmonary disease.

b. The veteran/service member tends to minimize the contribution tobacco had on his/her loved one’s death.

c. As the veteran/service member has become more accepting that his/her loved one died due to tobacco-related causes, his/her motivation for decreasing tobacco use increased.

10. Failure of Physical Training Tests (10)

a. The service member has failed required physical training tests due to decreased lung capacity.

b. The service member is at risk for restriction or sanction due to his/her failure at required physical training tasks.

c. As the service member’s tobacco use has decreased, his/her capability on required physical training tests has improved.

INTERVENTIONS IMPLEMENTED

1. Gather Addictive Behavior History (1)⁷⁶

a. The veteran/service member was asked to describe his/her pattern of nicotine use and other addictions in terms of the amount and pattern of use, symptoms of abuse, and negative life consequences that have resulted from addictive behaviors.

b. Active listening was provided as the veteran/service member openly discussed his/her addictive behavior history and gave complete data regarding its nature and extent.

c. It was reflected to the veteran/service member that he/she was minimizing his/her pattern of addictive behaviors and did not give reliable data regarding the nature and extent of his/her addiction problems.

d. As therapy has progressed, the veteran/service member has become more open in acknowledging the extent and seriousness of his/her nicotine dependence and addiction problems.

2. List Negative Consequences (2)

a. The veteran/service member was asked to make a list of the ways in which nicotine dependence has negatively impacted his/her physical, occupational, social, and interpersonal functioning and to process this list.

b. It was reflected to the veteran/service member that he/she has minimized the negative impact of his/her nicotine dependence on his/her physical, occupational, social, and interpersonal functioning.

c. The veteran/service member completed his/her list of negative impacts of nicotine dependence on his/her physical, occupational, social, and interpersonal functioning and was noted to acknowledge the negative consequences that he/she has experienced.

d. The veteran/service member has not completed the list of negative impacts on his/her physical, occupational, social, and interpersonal functioning and was redirected to do so.

3. Explain the Five Stages of Change (3)

a. The five stages of change were explained to the veteran/service member.

b. Information from The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy (Prochaska and DiClemente) was used to explain the five stages of change to the veteran/service member.

c. The veteran/service member was instructed about pre-contemplation, contemplation, preparation, action, and maintenance.

d. The veteran/service member was reinforced for his/her understanding of the five stages of change.

e. The veteran/service member did not display significant understanding about the five stages of change and was provided with remedial information in this area.

4. Assess Contemplation Stage (4)

a. The veteran/service member was assessed to as to whether he/she verbalizes a desire to stop using tobacco.

b. The veteran’s/service member’s level of contemplation to change was assessed.

c. The veteran/service member was assessed to be in the contemplation stage of change.

d. The veteran/service member was assessed to still be in the pre-contemplation stage of change.

5. Refer for Physical Examination (5)

a. The veteran/service member was referred for a thorough physical examination to determine any negative effects related to his/her nicotine dependence.

b. The veteran/service member has followed through with obtaining a physical examination and was told that his/her nicotine dependence has produced negative medical consequences.

c. The veteran/service member has obtained a physical examination from a physician and has been told that there are no significant medical effects of his/her nicotine dependence.

d. The veteran’s/service member’s physician has ordered medications that facilitate withdrawal from nicotine and assist in maintaining abstinence.

e. The veteran/service member has not followed through with obtaining a physical examination and was again directed to do so.

6. Educate about Health Risks (6)

a. The veteran/service member was educated about nicotine dependence and the negative effects of nicotine.

b. The veteran/service member was asked to identify several key points learned from the information about using tobacco.

c. Key points were processed with the veteran/service member.

d. The veteran/service member has become more open and acknowledging and accepting of his/her nicotine dependence; this progress was reinforced.

7. Assign Readings on Health Hazards of Smoking (7)

a. The veteran/service member was assigned to read material on nicotine dependence and its negative social, emotional, and medical consequences and to select several key ideas to discuss at a later session.

b. The veteran/service member was assigned to read information from these web links: www.cancer.gov/cancertopics/factsheet/tobacco/cancer; www.cancer.org.

c. The veteran/service member has read the information provided on nicotine dependency, etiology, and consequences, and key ideas were processed.

d. As a result of his/her reading assignment information on nicotine dependence, the veteran/service member has demonstrated an increased understanding of nicotine dep...

Table of contents

• PracticePlanners ® Series
• Title Page
• Copyright Page
• Dedication
• PRACTICEPLANNERS SERIES PREFACE
• Introduction
• ADJUSTMENT TO KILLING
• ADJUSTMENT TO THE MILITARY CULTURE
• AMPUTATION, LOSS OF MOBILITY, DISFIGUREMENT
• ANGER MANAGEMENT AND DOMESTIC VIOLENCE
• ANTISOCIAL BEHAVIOR IN THE MILITARY
• ANXIETY
• ATTENTION AND CONCENTRATION DEFICITS
• BEREAVEMENT DUE TO THE LOSS OF A COMRADE
• BORDERLINE PERSONALITY
• BRIEF REACTIVE PSYCHOTIC EPISODE
• CHRONIC PAIN AFTER INJURY
• COMBAT AND OPERATIONAL STRESS REACTION
• CONFLICT WITH COMRADES
• DEPRESSION
• DIVERSITY ACCEPTANCE
• FINANCIAL DIFFICULTIES
• HOMESICKNESS/LONELINESS
• INSOMNIA
• MILD TRAUMATIC BRAIN INJURY
• NIGHTMARES
• OPIOID DEPENDENCE
• PANIC/AGORAPHOBIA
• PARENTING PROBLEMS RELATED TO DEPLOYMENT
• PERFORMANCE-ENHANCING SUPPLEMENT USE
• PHOBIA
• PHYSIOLOGICAL STRESS RESPONSE—ACUTE
• POST-DEPLOYMENT REINTEGRATION PROBLEMS
• POSTTRAUMATIC STRESS DISORDER (PTSD)
• PRE-DEPLOYMENT STRESS
• SEPARATION AND DIVORCE
• SEXUAL ASSAULT BY ANOTHER SERVICE MEMBER
• SHIFT WORK SLEEP DISORDER
• SOCIAL DISCOMFORT
• SPIRITUAL AND RELIGIOUS ISSUES
• SUBSTANCE ABUSE/DEPENDENCE
• SUICIDAL IDEATION
• SURVIVOR’S GUILT
• TOBACCO USE