Reference no: EM132577776

Assignment: 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.