Walden NURS6650 Week 7 Assignment 2

NURS6650 Psychotherapy With Groups and Families

Week 7 Assignment 2

Practicum –
Assessing Client Family Progress

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.

The
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.

By Day 7

Submit your
Assignment.

Submission
and Grading Information

To submit
your completed Assignment for review and grading, do the following:

Please save
your Assignment using the naming convention “WK7Assgn2+last name+first
initial.(extension)” as the name.

Click the
Week 7 Assignment 2 Rubric to review the Grading Criteria for the Assignment.

Click the
Week 7 Assignment 2 link. You will also be able to “View Rubric” for grading
criteria from this area.

Next, from
the Attach File area, click on the Browse My Computer button. Find the document
you saved as “WK7Assgn2+last name+first initial.(extension)” and click Open.

If
applicable: From the Plagiarism Tools area, click the checkbox for I agree to
submit my paper(s) to the Global Reference Database.

Click on
the Submit button to complete your submission.