Assignment 2: Practicum Assessing Client Progress

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.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.