Learning Objectives Students will:
· Assess progress for clients receiving psychotherapy
· Differentiate progress notes from privileged notes
· Analyze preceptor’s use of privileged notes
· 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.