Part 1: Progress Note

Using the client from  your week 3 Assignment, address the following in a progress note (without violating HIPPA 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 towards goals)

Modifications of the treatment plan that were made based on progress/lack of progress

Clinical impressions regarding diagnosis and/or symptoms

Relevant psycho social 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/action taken

Medications used by the patient (even if the nurse psychotherapist was not the on e 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 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 judgement

NOTE: Be sure to exclude any information that should not be found in a discoverable progress note.

 

Part 2:Privileged Note

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.