Assessing Client Progress – (sample clinical documentation, the format of your choice).

Part 1: Progress Note (20 points)

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Using the client from your PMH 694 practicum, address the following in a progress note (without violating HIPAA regulations):

Treatment modality used and efficacy of the 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 (10 points)

Research the definition and purpose of a privileged psychotherapy note. Prepare a privileged note that you would use to document your impressions of therapeutic progress/therapy sessions for your client.

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
Play media comment.
and if so, describe the type of information he or she might include. If not, explain why.
“Assessing Client Progress” Rubric
“Assessing Client Progress” Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeEssential Treatment Details
Treatment modality/efficacy; treatment plan/progress/modifications; diagnostic impressions; medications; compliance.
8.0 to >5.0 pts
5.0 to >0.0 pts
0.0 pts
Needs Improvement
8.0 pts
This criterion is linked to a Learning OutcomeSafety Considerations
Safety issues; clinical emergencies/actions; abuse and mandatory reporting.
4.0 to >3.0 pts
3.0 to >0.0 pts
0.0 pts
Needs Improvement
4.0 pts
This criterion is linked to a Learning OutcomeConsent, Psychosocial & Termination
Informed consent; relevant psychosocial info/changes from original assessment; issues relevant to termination process.
4.0 to >2.0 pts
2.0 to >0.0 pts
0.0 pts
Needs Improvement
4.0 pts
This criterion is linked to a Learning OutcomeConsultations, Referrals, Clinical Judgment
Consultations; collaboration; referrals; recommendations; clinical judgment.
4.0 to >2.0 pts
2.0 to >0.0 pts
0.0 pts
Needs Improvement
4.0 pts
This criterion is linked to a Learning OutcomePrivileged Note
Reports and justifies issues that are not typically included in the progress note; explains preceptor’s use of privileged notes (if applicable).
10.0 to >5.0 pts
5.0 to >0.0 pts
0.0 pts
Needs Improvement
10.0 pts
Total Points: 30.0

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