Part 1: Progress Note Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): 1.) Treatment modality used and efficacy of approach 2.) Progress and/or lack of progress toward the mutually agreed-upon 3.) client goals (reference the Treatment planprogress toward goals) 4.) Modification(s) of the treatment plan that were made based on progress/lack of progress 5.) Clinical impressions regarding diagnosis and/or symptoms 6.) 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.) 7.) Safety issues 8.) Clinical emergencies/actions taken 9.) Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them) 10.) Treatment compliance/lack of compliance 11.) Clinical consultations 12.) Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.) 13.) Therapists recommendations, including whether the client agreed to the recommendations 14.) Referrals made/reasons for making referrals 15.) 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) 16.) Issues related to consent and/or informed consent for treatment 17.) Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported 18.) Information reflecting the therapists 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 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. 1.) The privileged note should include items that you would not typically include in a note as part of the clinical record. 3.) Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.
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