Practicum – Assessing Client Progress

  • Post category:Nursing
  • Reading time:3 mins read

Practicum – Assessing Client Progress

Nursing homework help

To prepare:

· Reflect on the client you selected for the Week 3 (See the attached case study for client selected in 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 (See attached resource).

 

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): (See sample paper)

 

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.