PRAC-6640-35 Practicum Week 7
This week, you assess progress for a client receiving psychotherapy and develop progress and privileged psychotherapy notes for the client.
Learning Resources
Required Readings
Optional Resources
- American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
- 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.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Assignment 1: 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.
- 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.
By Day 7
Assignment 2: Practicum – Week 5 and Week 6 Journal Submission
Learning Objectives
Students will:
- Develop diagnoses for clients receiving psychotherapy*
- Evaluate the efficacy of therapeutic approaches for clients*
- Analyze legal and ethical implications of counseling clients with psychiatric disorders*
By Day 7
Submit your Journal Entries for Week 5 and Week 6. Refer to Week 5 and Week 6 for additional guidance.
Submission
