Homework: Practicum - Assessing Client Family Progress
Learning Objectives
i. Create progress notes
ii. Create privileged notes
iii. Justify the inclusion or exclusion of information in progress and privileged
To prepare:
o Reflect on the client family you selected for the Week 3 Practicum Homework.
Task
Part I: Progress Note
Using the client family from your Practicum Homework, address in a progress note (without violating HIPAA regulations) the following:
i. Treatment modality used and efficacy of approach
ii. Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)
iii. Modification(s) of the treatment plan that were made based on progress/lack of progress
iv. Clinical impressions regarding diagnosis and or symptoms
v. Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
vi. Safety issues
vii. Clinical emergencies/actions taken
viii. Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
ix. Treatment compliance/lack of compliance
x. Clinical consultations
xi. Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
xii. The therapist's recommendations, including whether the client agreed to the recommendations
xiii. Referrals made/reasons for making referrals
xiv. Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
xv. Issues related to consent and/or informed consent for treatment
xvi. Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
xvii. Information reflecting the therapist's exercise of clinical judgment
Note: Be sure to exclude any information that should not be found in a discoverable progress note.
Part II: Privileged Note
Based on this readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Homework.
In your progress note, address the following:
i. Include items that you would not typically include in a note as part of the clinical record.
ii. Explain why the items you included in the privileged note would not be included in the client family's progress note.
iii. Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
Format your homework according to the following formatting requirements:
i) The answer should be typed, using Times New Roman font (size 12), double spaced, with one-inch margins on all sides.
ii) The response also includes a cover page containing the title of the homework, the student's name, the course title, and the date. The cover page is not included in the required page length.
iii) Also include a reference page. The Citations and references must follow APA format. The reference page is not included in the required page length.