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Using the client from your Week 3 Assignment address the following in a progress note

Using the client from your Week 3 Assignment address the following in a progress note

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.

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