Reference no: EM132481699

Assignment: 1. Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan-progress toward goals)

2. Modification(s) of the treatment plan that were made based on progress/lack of progress

3. Clinical impressions regarding diagnosis and/or symptoms

4. 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.)

5. Safety issues

6. Clinical emergencies/actions taken

7. Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

8. Treatment compliance/lack of compliance

9. Clinical consultations

10. Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)

11. Therapist's recommendations, including whether the client agreed to the recommendations

12. Referrals made/reasons for making referrals

13. 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)

14. Issues related to consent and/or informed consent for treatment

15. Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

16. 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, and if so, describe the type of information he or she might include. If not, explain why.