Assessing Client Progress

Reflect on the client you selected for the Week 3 (See the attached case study for client selected in 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 (See attached resource).

 

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): (See sample paper)

 

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.

 

References

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.

· Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)

· Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

 

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

 

Note: You will access this article from the Walden Library databases.

 

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

 

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

 

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.