Describe the clinical impressions regarding diagnosis

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Reference no: EM132386990

Assignment 2: Practicum - Assessing Client Family Progress

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.

The 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.

Reference no: EM132386990

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