Walden University NURS 6660 Assignment 2: Practicum – Assessing Client Progress

Walden University NURS 6660 Assignment 2: Practicum – Assessing Client Progress

Walden University NURS 6660 Assignment 2: Practicum – Assessing Client Progress

• 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.)

Assess progress for clients receiving psychotherapy
• 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
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.

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See below a sample paper on Walden University Nurs 6660 assignment 2: practicum – assessing client progress nursing assignment

Paper type: Research Paper
Course Level: Master
Subject Area: Nursing
# Pages: 2

Assessing the progress of the patient is an important component of every psychotherapeutic relationship. The clinician should keep progress and privilege notes as part of the treatment records. As Cameron and Turtle-Song (2002) explain, a clear progress note is usually written in the SOAP format where the clinician details the subjective data, objective data, assessment information, and treatment plan for the patient. Conversely, a privilege note is a documentation of the client’s private conversation with the client. Contents of privilege notes do not normally form part of the patient’s medical records. This paper provides details of a progress note and a privilege note for a 32-year-old female patient who presents with symptoms of generalized anxiety disorder.
Part One: Progress Note
The treatment modality that was chosen for the client is cognitive behavioral therapy (CBT). The approach has been effective in improving symptoms of generalized anxiety disorder. Furthermore, there is a positive progress towards the expected client goals. Such a conclusion is made because the client is organized, is able to sleep normally, concentrate in daily activities, is strong and cooperative, and has resumed work (Otte, 2011). No modifications have been made to the treatment plan because it generated the expected outcomes. Moreover, there are positive clinical impressions because the initially observed symptoms of generalized anxiety disorder have significantly improved. Again, the client is in a new relationship and feels very safe in her new life. No clinical emergencies have been taken up to this extent. Besides, the client is not under any type of medication.

The client has achieved the positive progress due to high treatment compliance. Additional factors that have resulted in the realization of positive health outcomes for the client include clinical consultations, collaboration with other healthcare professionals, and her agreement to the therapist’s recommendations. Neither referrals nor terminations have been made up to this extent. The clinician has discovered that the client’s abuse case was not reported. Generally, the therapist has conducted the therapeutic exercise efficiently and ethically as evidenced by his ability to issue the client with informed consent for treatment (Nijhawan et al., 2013).
Part Two: Privileged Note
The clinician should prepare a privileged psychotherapy note that documents his or her impression of the therapy sessions for the client. Based on the nature of the therapeutic progress, there are only two items that the privileged note for the female patient would contain. First, the therapist should state whether there is any form of disagreement between the patient and her family members. This information should include details of any issues that the client currently faces with her parents and close relatives. Besides, the healthcare professional should document the actual salary of the patient and who is responsible for planning how it is spent. These two items would not be included in the progress note as part of the clinical record (Lees et al., 2015).

The items included in the privileged note would not be included in the client’s progress note because they are irrelevant to the treatment process. As Lees at al. (2015) explain, in a privileged psychotherapy note, the healthcare professional should document the contents of conversations that were conducted during private counseling sessions. The information should be kept private and confidential for use by the clinician alone to guide the therapeutic relationship. In the current scenario, data concerning the client’s relationship and amount of income earned was gathered during the private counseling session and should be contained in the process note because they are not relevant for the treatment process.

References: Sample paper on Walden University Nurs 6660 assignment 2: practicum – assessing client progress

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(1), 286-292.

Lees, R., Sveen, J., Stevens, M., & McNally, M. (2015). Progress notes v. process notes. Retrieved from http://www.robertalees.com/wp-content/uploads/sites/6205/2015/05/Process-vs-Progress-Notes.pdf

Nijhawan, L. P., Janodia, M. D., Muddukrishna, B, Bhat, K., Bairy, K, Udupa, N., & Musmade, P. B. (2013). Informed consent: Issues and challenges. Journal of Advanced Pharmaceutical Technology & Research, 4(3), 134-140. doi:  10.4103/2231-4040.116779

Otte, C. (2011). Cognitive behavioral therapy in anxiety disorders: Current state of the evidence. Dialogues in Clinical Neuroscience, 13(4), 413-421.

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