Feb 7, 2024 Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35
Assignment 1: Practicum – Assessing Client Progress PRAC 6640-35
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
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To access your rubric:
Week 7 Assignment 1 Rubric
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Submit Your Assignment by Day 7
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Week 7 Assignment 1
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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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