NURS 6650 Week 7 Assignment 2: Practicum – 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
Evaluate preceptor notes
To prepare:
Reflect on the client family you selected for the Week 3 Practicum Assignment.
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.
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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.
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.
By Day 7
Submit your Assignment.
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NURS 6650 Week 7 Assignment 2: Assessing Client Family Progress
They will:
Notes on progress
Make secret notes
Include or exclude work-in-progress and privileged notes.
Review preceptor notes.
Prep:
Consider the client family you choose for Week 3 Practicum.
The Task
1st Progress Note
Assuming you used the client family from Week 3’s Practicum Assignment, include the following in your progress note:
Treatment modality and approach efficacy
Client goals progress (or lack thereof) (reference the treatment plan for progress toward goals)
Modifications made to the treatment plan based on progress or lack thereof
diagnostic or symptomatic impressions
Marriage, separation/divorce, new relationships, move to a new house/apartment, career change)
SECURITY
Acute care/interventions
Medication taken by the patient, even if not prescribed by the nurse psychotherapist
Treatment adherence/non-adherence
Consultations
Phone consultations with doctors, psychiatrists, and marriage/family therapists
Whether the client agreed to the therapist’s advice
Reasons for making referrals
Termination/termination-related issues (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
Concerns about permission and/or informed consent for treatment Information about child, elder, or dependent adult abuse, including reports of abuse
Clinical judgment information from the therapist
Don’t include information that shouldn’t appear in a discoverable progress note.
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Part 2: Special Note
Prepare a privileged psychotherapy note based on this week’s readings for your client family from the Week 3 Practicum Assignment.
In your progress remark, mention:
Include items that you wouldn’t normally put in a clinical note.
Explain why the protected information wouldn’t be included in the client’s progress note.
Do your preceptor use privileged notes? Explain what facts he or she might include. If not, why not?
Day 7
Submit your Task.
