Assignment 1: Practicum – Assessing Client Family Progress PRAC 6650

Assignment 1: Practicum – Assessing Client Family Progress (Due in Week 8)
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.
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
 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
family from the Week 3 Practicum Assignment.
In your progress note, address the following:
 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 family’s progress note.
 Explain whether your preceptor uses privileged notes. If so, describe the type of
information he or she might include. If not, explain why.
No Assignment due this week.
Submit Assignment By Day 7 of Week 8.

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Learning Resources
Optional Resources

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and
standards of practice (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-
to guide for evidence-based practice. New York, NY: Springer.

Assignment 1: Practicum – Assessing Client Family Progress PRAC 6650