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.

Solution:

Part 1: Progress Note

The patient selected in week 3 was J.J, a 27 year-old African American female who presented symptoms of- and diagnosed with moderate post-partum depression (PPD).

Treatment modality used and efficacy of approach

The treatment modality used is Cognitive Behavioral Therapy (CBT) and support groups. CBT is a talk psychotherapy which aids in modifying a patient’s negative behaviors, thoughts, attitudes, as well as emotional response associated with psychological distress (Huang, Zhao, Qiang, & Fan, 2018). CBT is highly effective in helping patients suffering PPD which is mental health disorder characterized by onset of negative thoughts, attitudes, behaviors and emotional responses related to stress that comes with new born responsibilities (Huang et al., 2018).

Support group on the other hand involves interaction with others going through the same situations. It is highly crucial for individuals with PDD symptoms to seek support as it significantly contributes a lot in lifting the fog of PDD and keeping it far away (Morikawa et al., 2015). Isolation and loneliness usually worsen depression as patients that stay on their own find it considerably difficult to maintain and sustain perspective and effort needed to deal with depression. As such, it is highly crucial for PDD patients to maintain close relationships as well as social activities to be able to cope with their health situation (Morikawa et al., 2015).Please click the icon below to purchase full solution at $10