Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35

Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35

Assignment 1: Practicum – Assessing Client Progress
Learning Objectives
Students will:
 Assess progress for clients receiving psychotherapy
 Differentiate progress notes from privileged notes
 Analyze preceptor’s use of privileged notes
To prepare:
 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.
By Day 7
Submit your Assignment.
Submission
To submit your completed Assignment for review and grading, do the following:
 Please save your Assignment using the following naming convention:
“WK7Assgn1+lastname+first initial”.
 Click the Week 7 Assignment 1 link.
 Next, from the Attach File area, click on the Browse My Computer button. Find the
document you saved as “WK7Assgn1+last name+first initial.(extension)” and
click Open. If you are submitting multiple files, repeat until all files are attached.
 Click on the Submit button to complete your submission.
Grading Criteria

To access your rubric:
Week 7 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:
Submit your Week 7 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 7

To submit your Assignment:
Week 7 Assignment 1

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35

 

Learning Resources
Required Readings

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP
format. Journal of Counseling and Development, 80(3), 286-292.

Optional Resources
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and
standards of practice (2nd ed.). Washington, DC: Author.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-
to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing
Company.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.

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