Assessing Client Progress

 
 
 

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Assessing Client Progress

Assignment

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

  1. Treatment modality used and efficacy of approach 
  2. Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
  3. Modification(s) of the treatment plan that were made based on progress/lack of progress
  4. Clinical impressions regarding diagnosis and/or symptoms
  5. 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.)
  6. Safety issues 
  7. Clinical emergencies/actions taken 
  8. Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
  9. Treatment compliance/lack of compliance
  10. Clinical consultations
  11. Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
  12. Therapist’s recommendations, including whether the client agreed to the recommendations
  13. Referrals made/reasons for making referrals 
  14. 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)
  15. Issues related to consent and/or informed consent for treatment 
  16. Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
  17. Information reflecting the therapist’s exercise of clinical judgment

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.

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