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 notesTo 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.

Solution:

Part 1: Progress Note

Presenting Problem

Miss Paula and her son were referred to the clinic after possible organic cause of their symptoms was ruled out. Miss Paula complains of increased depression, stress, alcohol consumption, and insomnia which started 12 years ago following her husband’s death who was a veteran in war in Afghanistan. She reports that since her husband’s death which occurred in her third month in pregnancy, she has not been able to engage in religious activities like before. She admits suicidal ideations but then she would not wish to leave her son all alone. She further reports that her son’s recent diagnosis made her feel increasingly stressed and she wishes her husband was there to support her through their son’s recovery. Following assessment and examination, Miss is diagnosed with mild to moderate depression. Jones on the other hand has been recently diagnosed with Attention Deficit / Hyperactivity Disorder (ADHD).

Treatment modality used and efficacy of approach

The treatment modality for Miss Paula is to continue with using the antidepressants and to start cognitive-behavioral therapy (CBT). As described by Arroll et al. (2016) CBT is a psychosocial intervention aimed at improving one’s mental health by focusing on modifying the challenging and unhelpful cognitive distortions as well as behaviors for improvement of emotional regulation and functionality and development of personal strategies for coping with challenges and resolving presenting problems…..Please click the icon below to purchase full  solution at $10