Learning Objectives

Students will:

· Create progress notes

· Create privileged notes

· Justify the inclusion or exclusion of information in progress and privileged notes

· Evaluate preceptor notes

To prepare:

· Reflect on the client family you selected for the Week 3 Practicum Assignment.

The Assignment

Part 1: Progress Note

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

· Treatment modality used and efficacy of approach

· Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)

· 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)

· The 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 (e.g., 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