“PLEASE PAY ATTENTION TO THE ATTACHED INFORMATION
5 REFERENCES NOT MORE THAN 5 YEARS
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.
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.)
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
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
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.