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 (SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE) · Evaluate preceptor notes To prepare: · Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE), 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. (SEE ATTACHED WEEK 3 NOTE), 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.
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