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Using the client family from your Week 3 Practicum

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.

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