receiving psychotherapy

/in /by

receiving psychotherapy

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.

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Create a 4-6 page paper with you , as a presenter, in which you will propose an evidence-based plan to improve the outcomes for a patient and examine how remote collaboration provided benefits or challenges to designing and delivering the care. As technologies and the health care industry continue to evolve, remote care, diagnosis, and collaboration are becoming increasingly more regular methods by which nurses are expected to work. Learning the ways in which evidence-based models and care can help remote work produce better outcomes will become critical for success. Additionally, understanding how to leverage EBP principles in collaboration will be important in the success of institutions delivering quality, safe, and cost-effective care. It could also lead to better job satisfaction for those engaging in remote collaboration. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision. Reflect on which evidence was most relevant and useful when making decisions regarding the care plan. Competency 3: Apply an evidence-based practice model to address a practice issue. Explain the ways in which an EBP model was used to help develop the care plan. Competency 4: Plan care based on the best available evidence. Propose an evidence-based care plan to improve the safety and outcomes for a patient. Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence. Identify benefits and strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Communicate in a professional manner that is easily audible and uses proper grammar, including a reference list formatted in current APA style. Professional Context Remote care and diagnosis is a continuing and increasingly important method for nurses to help deliver care to patients to promote safety and enhance health outcomes. Understanding best EBPs and building competence in delivering nursing care to remote patients is a key competency for all nurses. Additionally, in some scenarios, while you may be delivering care in person you may be collaborating with a physician or other team members who are remote. Understanding the benefits and challenges of interdisciplinary collaboration is vital to developing effective communication strategies when coordinating care. So, being proficient at communicating and working with remote health care team members is also critical to delivering quality, evidence-base care. Scenario The Vila Health: Remote Collaboration on Evidence-Based Care simulation provide the context for this assessment. Instructions Before beginning this assessment, make sure you have worked through the following media: Vila Health: Remote Collaboration on Evidence-Based CarePlease find attached word document with Villa Health Scenario For this assessment, you are a presenter! You will create a 5–10-minute video using Kaltura or similar software. In the video: Propose an evidence-based care plan that you believe will improve the safety and outcomes of the patient in the Vila Health Remote Collaboration on Evidence-Based Care media scenario. Discuss the ways in which an EBP model and relevant evidence helped you to develop and make decision about the plan you proposed Wrap up your video by identifying the benefits of the remote collaboration in the scenario, as well as discuss strategies you found in the literature or best practices that could help mitigate or overcome one or more of the collaboration challenges you observed in the scenario. Be sure you mention any articles, authors, and other relevant sources of evidence that helped inform your video. Important: You are required to submit an APA-formatted reference list of the sources you cited specifically in your video or used to inform your presentation. The following media is an example learner submission in which the speaker successfully addresses all competencies in the assessment. Exemplar Kaltura Reflection. Please note that the scenario that the speaker discusses in the exemplar is different from the Vila Health scenario you should be addressing in your video. So, the type of communication expected is being model, but the details related to the scenario in your submission will be different. Make sure that your video addresses the following grading criteria: Propose an evidence-based care plan to improve the safety and outcomes for a patient based on the Vila Health Remote Collaboration on Evidence-Care media scenario. Explain the ways in which an EBP model was used to help develop the care plan. Reflect on which evidence was most relevant and useful when making decisions regarding the care plan. Identify benefits and strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Communicate in a professional manner that is easily audible and uses proper grammar, including a reference list formatted in current APA style. Additional Requirements Your assessment should meet the following requirements: Length of video: 5–10 minutes. References: Cite at least three professional or scholarly sources of evidence to support the assertions you make in your video. Include additional properly cited references as necessary to support your statements. APA reference page: Submit a correctly formatted APA reference page that shows all the sources you used to create and deliver your video. Be sure to format the reference page according to current APA style.
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