Assessing Client Family Progress

Learning Objectives

Assignment 1: Practicum – Assessing Client Family Progress

Learning Objectives

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.

Assignment 1: Practicum

–

Assessing Client Family Progress

Learning Objectives

T

o prepare:

·

Reflect on the client family you selected for the Week 3 Practicum Assignmen

t.

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 prog

ress 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

·

Rele

vant 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 o

f 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

·

Informat

ion 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

Assignment 1: Practicum – Assessing Client Family Progress

Learning Objectives

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