Assessing Client Family Progress

Learning Objectives

Students will:

· 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

To prepare:

· Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),

                                                             The 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. (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 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.