Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35

Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35 

Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35  

 

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Assignment 1: Practicum – Assessing Client Progress

Learning Objectives

Students will:

 Assess progress for clients receiving psychotherapy

 Differentiate progress notes from privileged notes

 Analyze preceptor’s use of privileged notes

To prepare:

 Reflect on the client you selected for the Week 3 Practicum Assignment.

 

 Review the Cameron and Turtle-Song (2002) article in this week’s Learning

Resources for guidance on writing case notes using the SOAP format.

The Assignment

Part 1: Progress Note

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

 

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 from

the Week 3 Practicum Assignment.

 The privileged note should 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’s progress note.

 Explain whether your preceptor uses privileged notes, and if so, describe the type of

information he or she might include. If not, explain why.

By Day 7

Submit your Assignment.

Submission

To submit your completed Assignment for review and grading, do the following:

 Please save your Assignment using the following naming convention:

“WK7Assgn1+lastname+first initial”.

 Click the Week 7 Assignment 1 link.

 Next, from the Attach File area, click on the Browse My Computer button. Find the

document you saved as “WK7Assgn1+last name+first initial.(extension)” and

click Open. If you are submitting multiple files, repeat until all files are attached.

 Click on the Submit button to complete your submission.

Grading Criteria

 

To access your rubric:

Week 7 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

 

To check your Assignment draft for authenticity:

Submit your Week 7 Assignment 1 draft and review the originality report.

 

Submit Your Assignment by Day 7

 

To submit your Assignment:

Week 7 Assignment 1

Learning Resources

Required Readings

 

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP

format. Journal of Counseling and Development, 80(3), 286-292.

 

Optional Resources

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and

standards of practice (2nd ed.). Washington, DC: Author.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-

to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing

Company.

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.