Assignment 1: Practicum – Assessing Client Family Progress
· Create progress notes
· Create privileged notes
· Justify the inclusion or exclusion of information in progress and privileged notes
· Evaluate preceptor notes
· Reflect on the client family you selected for the Week 3 Practicum Assignment.
Part 1: Progress Note
Using the client family from your Week 3 Practicum Assignment,( Will Attach) 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
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 family from the Week 3 Practicum Assignment.
In your progress note, address the following:
· 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 family’s progress note.
· Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
Resources ( need 3 references).
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Boston, MA: Pearson.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
The assignment 1 requires the students to create two types of notes, namely progress note and privileged note, based on the client family selected for the Week 3 Practicum Assignment. The aim is to enable the student to document the client’s progress accurately and efficiently while meeting the ethical and legal guidelines set by HIPAA regulations. The students are also required to evaluate their preceptor notes and exclude any information that should not be present in a discoverable progress note.
To complete this assignment, the students should follow the guidelines provided and ensure that every section in the progress note is addressed. Additionally, they need to use available resources to support their work and provide three references. The progress notes should document the client’s progress and utilized an evidence-based approach. The privileged note is intended to be more subjective and reflective than a progress note, with the focus on the clinician’s impressions and conclusions regarding the therapy sessions. The preceptor notes evaluated must adhere to HIPAA regulations, ethical, and legal guidelines. It is crucial to be accurate, concise, and document only what is necessary in both notes.
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