Assignment 2: Practicum – Assessing Client Progress

41208Part 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

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