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.

Assessing Client Progress

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