Practicum \u2013 Assessing Client Family Progress<\/p>\n
Learning Objectives<\/p>\n
Students will:<\/p>\n
\u00b7 Create progress notes<\/p>\n
\u00b7 Create privileged notes<\/p>\n
\u00b7 Justify the inclusion or exclusion of information in progress and privileged notes (SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE)<\/p>\n
\u00b7 Evaluate preceptor notes<\/p>\n
To prepare:<\/p>\n
\u00b7 Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),<\/p>\n
The Assignment<\/p>\n
Part 1: Progress Note<\/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
\u00b7 Treatment modality used and efficacy of approach<\/p>\n
\u00b7 Progress and\/or lack of progress toward the mutually agreed-upon client goals <\/p>\n
(reference the treatment plan for progress toward goals)<\/p>\n
\u00b7 Modification(s) of the treatment plan that were made based on progress\/lack of <\/p>\n
progress<\/p>\n
\u00b7 Clinical impressions regarding diagnosis and or symptoms<\/p>\n
\u00b7 Relevant psychosocial information or changes from original assessment (e.g., <\/p>\n
marriage, separation\/divorce, new relationships, move to a new <\/p>\n
house\/apartment, change of job)<\/p>\n
\u00b7 Safety issues<\/p>\n
\u00b7 Clinical emergencies\/actions taken<\/p>\n
\u00b7 Medications used by the patient, even if the nurse psychotherapist was not the <\/p>\n
one prescribing them<\/p>\n
\u00b7 Treatment compliance\/lack of compliance<\/p>\n
\u00b7 Clinical consultations<\/p>\n
\u00b7 Collaboration with other professionals (e.g., phone consultations with physicians, <\/p>\n
psychiatrists, marriage\/family therapists)<\/p>\n
\u00b7 The therapist\u2019s recommendations, including whether the client agreed to the <\/p>\n
recommendations<\/p>\n
\u00b7 Referrals made\/reasons for making referrals<\/p>\n
\u00b7 Termination\/issues that are relevant to the termination process (e.g., client <\/p>\n
informed of loss of insurance or refusal of insurance company to pay for <\/p>\n
continued sessions)<\/p>\n
\u00b7 Issues related to consent and\/or informed consent for treatment<\/p>\n
\u00b7 Information concerning child abuse and\/or elder or dependent adult abuse, <\/p>\n
including documentation as to where the abuse was reported<\/p>\n
\u00b7 Information reflecting the therapist\u2019s exercise of clinical judgment<\/p>\n
Note: Be sure to exclude any information that should not be found in a discoverable progress note.<\/p>\n
Part 2: Privileged Note<\/p>\n
\u00b7 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. (SEE ATTACHED WEEK 3 NOTE),<\/p>\n
In your progress note, address the following:<\/p>\n
\u00b7 Include items that you would not typically include in a note as part of the clinical record.<\/p>\n
\u00b7 Explain why the items you included in the privileged note would not be included in the client family\u2019s progress note.<\/p>\n
\u00b7 Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.<\/p>\n \n
Practicum \u2013 Assessing Client Family Progress Learning Objectives Students will: \u00b7 Create progress notes \u00b7 Create privileged notes \u00b7 Justify the inclusion or exclusion of information [\u2026]<\/span><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[],"tags":[],"aioseo_notices":[],"yoast_head":"\n