This week, you assess progress for a client receiving psychotherapy and develop progress and privileged psychotherapy notes for the client.
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286-292.
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.
Assignment 1: Practicum – Assessing Client Progress
Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
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.
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.)
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
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.
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.
To access your rubric:
Week 7 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 7 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7
To submit your Assignment:
Week 7 Assignment 1
Assignment 2: Practicum – Week 5 and Week 6 Journal Submission
Develop diagnoses for clients receiving psychotherapy*
Evaluate the efficacy of therapeutic approaches for clients*
Analyze legal and ethical implications of counseling clients with psychiatric disorders*
By Day 7
Submit your Journal Entries for Week 5 and Week 6. Refer to Week 5 and Week 6 for additional guidance.
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