Walden NURS6640 Week 7 Assignment 2 Latest 2019 March

NURS6640 Psychotherapy With Individuals

Week 7 Assignment 2

Practicum – Assessing Client Progress

Learning Objectives

Students will:

Assess progress for clients receiving psychotherapy

Differentiate progress notes from privileged notes

Analyze preceptor’s use of privileged notes

To prepare:

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.

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):

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.

By Day 7

Submit your Assignment.

Submission

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the following naming convention: “WK7Assgn2+lastname+first initial”.

Click the Week 7 Assignment 2 link.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn2+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.