Safety issues

Assignment 1: 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.

Assignment

Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment,( Will Attach) 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.

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.

Resources ( need 3 references).

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Boston, MA: Pearson.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.

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