NURS6640 Week 7 Latest Assignment 2: Practicum Assessing Client Progress

Practicum Assessing Client Progress
Learning
Objectives
Students
will:
Assess
progress for clients receiving psychotherapy
Differentiate
progress notes from privileged notes
Analyze
preceptor’s use of privileged notes

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To prepare:
Reflect on
the client you selected for the Week 3 Practicum Assignment.
Review the
Cameron and Turtle-Song (2002) article in this week’s Learning Resources for
guidance on writing case notes using the SOAP format.
The
Assignment
Part 1:
Progress Note
Using the
client from your Week 3 Assignment, address the following in a progress note
(without violating HIPAA regulations):
Treatment
modality used and efficacy of approach
Progress
and/or lack of progress toward the mutually agreed-upon client goals (reference
the Treatment plan—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 (i.e., marriage,
separation/divorce, new relationships, move to a new house/apartment, change of
job, etc.)
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 (i.e., phone consultations with physicians,
psychiatrists, marriage/family therapists, etc.)
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 (i.e., 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 from the Week 3 Practicum Assignment.

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The privileged note should 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’s progress note.
Explain
whether your preceptor uses privileged notes, and if so, describe the type of
information he or she might include. If not, explain why.
By Day 7
Submit your
Assignment.
Submission
To submit
your completed Assignment for review and grading, do the following:
Please save
your Assignment using the following naming convention:
“WK7Assgn2+lastname+first initial”.
Click the
Week 7 Assignment 2 link.
Next, from
the Attach File area, click on the Browse My Computer button. Find the document
you saved as “WK7Assgn2+last name+first initial.(extension)” and click Open. If
you are submitting multiple files, repeat until all files are attached.
Click on
the Submit button to complete your submission.