Practicum Assessing Client Family Progress
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
Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),
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
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)
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
Collaboration with other professionals (e.g., phone consultations with physicians,
psychiatrists, marriage/family therapists)
The therapists recommendations, including whether the client agreed to the
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
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 therapists 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 weeks 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 familys 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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