Nursing.

Assignment 1: Practicum – Assessing Client Family Progress (Due in Week 8)

Learning Objectives

Students will:

• Create progress notes


• Create privileged notes


• Justify the inclusion or exclusion of information in progress and privileged notes


• Evaluate preceptor notes

To prepare:

• Reflect on the client family you selected for the Week 3 Practicum Assignment.

Assignment

Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:

• Treatment modality used and efficacy of approach


• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)


• Modification(s) of the treatment plan that were made based on progress/lack of progress


• Clinical impressions regarding diagnosis and or symptoms


• Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)


• Safety issues


• Clinical emergencies/actions taken


• Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them


• Treatment compliance/lack of compliance


• Clinical consultations


• Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)


• The therapist’s recommendations, including whether the client agreed to the recommendations


• Referrals made/reasons for making referrals


• 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)


• Issues related to consent and/or informed consent for treatment


• Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported


• 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 2: Privileged Note

Based on this week’s 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 Assignment.

In your progress note, address the following:

• Include items that you would not typically include in a note as part of the clinical record.


• Explain why the items you included in the privileged note would not be included in the client family’s progress note.


• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.