Learning Objectives<\/h4>\nStudents will:<\/strong><\/h6>\n\n- Create progress notes<\/li>\n
- Create privileged notes<\/li>\n
- Justify the inclusion or exclusion of information in progress and privileged<\/li>\n<\/ul>\n
To prepare:<\/strong><\/h6>\n\n- Reflect on the client family you selected for the Week 3 Practicum Assignment.<\/li>\n<\/ul>\n
Assignment<\/h4>\n
Part 1: Progress Note<\/strong><\/p>\nUsing the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:<\/p>\n
\n- Treatment modality used and efficacy of approach<\/li>\n
- Progress and\/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)<\/li>\n
- Modification(s) of the treatment plan that were made based on progress\/lack of progress<\/li>\n
- Clinical impressions regarding diagnosis and or symptoms<\/li>\n
- Relevant psychosocial information or changes from original assessment (e.g., marriage, separation\/divorce, new relationships, move to a new house\/apartment, change of job)<\/li>\n
- Safety issues<\/li>\n
- Clinical emergencies\/actions taken<\/li>\n
- Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them<\/li>\n
- Treatment compliance\/lack of compliance<\/li>\n
- Clinical consultations<\/li>\n
- Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage\/family therapists)<\/li>\n
- The therapist\u2019s recommendations, including whether the client agreed to the recommendations<\/li>\n
- Referrals made\/reasons for making referrals<\/li>\n
- 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)<\/li>\n
- Issues related to consent and\/or informed consent for treatment<\/li>\n
- Information concerning child abuse and\/or elder or dependent adult abuse, including documentation as to where the abuse was reported<\/li>\n
- Information reflecting the therapist\u2019s exercise of clinical judgment<\/li>\n<\/ul>\n
Note:<\/strong><\/em> Be sure to exclude any information that should not be found in a discoverable progress note.<\/em><\/p><\/blockquote>\nPart 2: Privileged Note<\/strong><\/p>\nBased on this week\u2019s 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.<\/p>\n
In your progress note, address the following:<\/p>\n
- \n
- Create progress notes<\/li>\n
- Create privileged notes<\/li>\n
- Justify the inclusion or exclusion of information in progress and privileged<\/li>\n<\/ul>\n
To prepare:<\/strong><\/h6>\n
- \n
- Reflect on the client family you selected for the Week 3 Practicum Assignment.<\/li>\n<\/ul>\n
Assignment<\/h4>\n
Part 1: Progress Note<\/strong><\/p>\n
Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:<\/p>\n
- \n
- Treatment modality used and efficacy of approach<\/li>\n
- Progress and\/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)<\/li>\n
- Modification(s) of the treatment plan that were made based on progress\/lack of progress<\/li>\n
- Clinical impressions regarding diagnosis and or symptoms<\/li>\n
- Relevant psychosocial information or changes from original assessment (e.g., marriage, separation\/divorce, new relationships, move to a new house\/apartment, change of job)<\/li>\n
- Safety issues<\/li>\n
- Clinical emergencies\/actions taken<\/li>\n
- Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them<\/li>\n
- Treatment compliance\/lack of compliance<\/li>\n
- Clinical consultations<\/li>\n
- Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage\/family therapists)<\/li>\n
- The therapist\u2019s recommendations, including whether the client agreed to the recommendations<\/li>\n
- Referrals made\/reasons for making referrals<\/li>\n
- 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)<\/li>\n
- Issues related to consent and\/or informed consent for treatment<\/li>\n
- Information concerning child abuse and\/or elder or dependent adult abuse, including documentation as to where the abuse was reported<\/li>\n
- Information reflecting the therapist\u2019s exercise of clinical judgment<\/li>\n<\/ul>\n
Note:<\/strong><\/em> Be sure to exclude any information that should not be found in a discoverable progress note.<\/em><\/p><\/blockquote>\n
Part 2: Privileged Note<\/strong><\/p>\n
Based on this week\u2019s 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.<\/p>\n
In your progress note, address the following:<\/p>\n
- Reflect on the client family you selected for the Week 3 Practicum Assignment.<\/li>\n<\/ul>\n
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