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),
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.
