regarding diagnosis and/or symptoms

Assignment 2: Practicum – 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( See attached)

· 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( See attached)

· 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.

Resources for reference ( Need 3+references).

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

• Standard 4 “Planning” (pages 50-51)

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 5, “Supportive and      Psychodynamic Psychotherapy” (pp. 238–242)
• Chapter 9, “Interpersonal Psychotherapy” (pp.      347–368)

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

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286-292.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.