Practicum Assignment
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
