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
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 prepares 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 Submit your Assignment. (PLEASE REFER TO THE JOUURNAL ENTRY OF WEEK 3 UPLOADED FOR THE PATIENT INFORMATION)
Rubric Detail Select Grid View or List View to change the rubric's layout. Name: NURS_6640_Week7_Assignment2_Rubric • Grid View • List View Show Descriptions Quality of Work Submitted: The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.-- Satisfactory 26 (26%) - 30 (30%) Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics. Unsatisfactory 0 (0%) - 25 (25%) Assignment superficially meets some of the expectations.Two or more required topics are either not addressed or inadequately addressed. Quality of Work Submitted: The purpose of the paper is clear.-- Satisfactory 4 (4%) - 5 (5%) Purpose of the assignment is stated, yet is brief and not descriptive. Unsatisfactory 0 (0%) - 3 (3%) No purpose statement was provided. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student's ability to: Understand and interpret the assignment's key concepts.-- Satisfactory 8 (8%) - 10 (10%) Demonstrates a clear understanding of key concepts. Unsatisfactory 0 (0%) - 7 (7%) Shows a lack of understanding of key concepts, deviates from topics. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student's ability to: Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.-- Satisfactory 16 (16%) - 20 (20%) Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view. Unsatisfactory 0 (0%) - 15 (15%) Includes and integrates specific information from 0 to 1 resource to support major points and point of view. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student's ability to: Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.-- Satisfactory 16 (16%) - 20 (20%) Summarizes information gleaned from sources to support major points, but does not synthesize. Unsatisfactory 0 (0%) - 15 (15%) Rarely or does not interpret, apply, and synthesize concepts, and/or strategies. Written Expression and Formatting Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused--neither long and rambling nor short and lacking substance.-- Satisfactory 4 (4%) - 5 (5%) Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 80% of the time. Unsatisfactory 0 (0%) - 3 (3%) Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time. "Written Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation"-- Satisfactory 3 (3%) - 5 (5%) Contains a few (1-2) grammar, spelling, and punctuation errors. Unsatisfactory 0 (0%) - 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. "Written Expression and Formatting The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list."-- Satisfactory 3 (3%) - 5 (5%) Contains a few (1-2) APA format errors. Unsatisfactory 0 (0%) - 2 (2%) Contains many (≥ 5) APA format errors. Total Points: 100 Name: NURS_6640_Week7_Assignment2_Rubric
ANSWER.
PAPER DETAILS
Academic Level
Masters
Subject Area
Nursing
Paper Type
Admission - Application Essay
Number of Pages
5 Page(s)/1375 words
Sources
5
Format
APA
Spacing
Double Spacing
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