Practicum – Assessing Client Family Progress
· Justify the inclusion or exclusion of information in progress and privileged notes (
SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE)
· 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:
· 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
· Relevant psychosocial information or changes from original assessment (e.g.,
marriage, separation/divorce, new relationships, move to a new
house/apartment, change of job)
· Medications used by the patient, even if the nurse psychotherapist was not the
one prescribing them
· 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
· 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)
· Information concerning child abuse and/or elder or dependent adult abuse,
including documentation as to where the abuse was reported
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),
· 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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