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.