Assessing Client Family Progress

Assessing Client Family Progress

Learning Objectives

Students will:

· Create progress notes

· Create privileged notes

· Justify the inclusion or exclusion of information in progress and privileged notes (SEE ATTACHED SAMPLE OF PROGRESS AND PRIVILIGED NOTE)

· Evaluate preceptor notes

To prepare:

· Reflect on the client family you selected for the Week 3 Practicum Assignment (SEE ATTACHED WEEK 3 NOTE),

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                                                             The Assignment

                 Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment 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. (SEE ATTACHED WEEK 3 NOTE),

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.Assessing Client Family Progress

MORE INFO 

Assessing Client Family Progress

Introduction

A family assessment is a critical component of an effective care plan. It can help providers and families work together to create a plan that will be most beneficial for each individual involved. Family assessments are often used by psychologists, psychiatrists, social workers and other mental health professionals for their clients who are receiving treatment for mental illness or substance abuse problems.

Client Family Progress Matrix

The Client Family Progress Matrix is a tool that you can use to assess your clients’ family progress. It helps you understand what’s happening in the lives of your clients and their families, which will help you improve your interventions.

The following are some things that are important to know about this tool:

• It’s not just for parents! You can use it with all types of clients, including children, teens and adults.

• The matrix has four quadrants; each contains an individual or group who plays an important role in the client’s life (for example: spouse, parent(s), child(ren)).

Adherence

Adherence is the ability of clients, providers and the team to follow through on the plan. This can be measured in several ways:

• How often they are following through on their treatment goals and expectations.

• How well they are complying with any agreements or contracts related to their care (e.g., medication adherence).

• How well each party has been communicating with one another throughout this process.

Family Functioning

Family functioning is the ability of a family to adapt and function together. The following categories describe how well families adapt to changes in their environment:

• Family cohesion (the degree to family members are connected)

• Family adaptability (the ability of a family to change with the times)

• Conflict within the family, including conflict between parents, among siblings and within same-sex couples.

Progress toward Goal Completion

The client family has completed all required tasks and goals.

• This means that the family met the criteria for goal completion, including meeting all expectations about their progress toward achieving a particular outcome or goal.

• They have also demonstrated that they can live independently in the community by living off their own resources (e.g., food stamps).

Takeaway:

• The main idea of the article is that you can use a number of tools to help assess client family progress.

• You should have an open mind and be willing to try new things, as long as they’re within your scope of practice.

Conclusion

As you can see, the Client Family Progress Matrix is a great way to get an overview of how well your clients are doing in their therapy. This is also a useful tool when working with psychotherapy groups or families of more than one child.