Practicum Assessing Client Wk7A2 What Is Assessi

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Practicum Assessing Client Wk7A2 What Is Assessi

Practicum – Assessing Client Family Progress

Objectives: Create progress notes, Create privileged notes, Justify the inclusion or exclusion of information in progress and privileged notes,Evaluate preceptor notes

To prepare: Reflect on the client family in the uploaded document.

ACTUAL ASSIGNMENT

PLEASE Addressed each of the bullets with a subtopic, use the resources, you can use other references within last five years only to 2019. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations)

Part 1: Progress Note

Using the client family in the uploaded document, 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

Part 2: Privileged Note

Based on the resources/references, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family in the uploaded document.

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.

References/Resources

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

  • Standard 5B “Health Teaching and Health Promotion” (pages 55-56)

Nichols, M. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson.

  • Chapter 8, “Experiential Family Therapy” (pp. 129–147)
  • Chapter 13, “Narrative Therapy” (pp. 243–258)

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.

  • “Genograms” pp. 137-142

Cohn, A. S. (2014). Romeo and Julius: A narrative therapy intervention for sexual-minority couples. Journal of Family Psychotherapy, 25(1), 73–77. doi:10.1080/08975353.2014.881696

Escudero, V., Boogmans, E., Loots, G., & Friedlander, M. L. (2012). Alliance rupture and repair in conjoint family therapy: An exploratory study. Psychotherapy, 49(1), 26–37. doi:10.1037/a0026747

Freedman, J. (2014). Witnessing and positioning: Structuring narrative therapy with families and couples. Australian & New Zealand Journal of Family Therapy, 35(1), 20–30. doi:10.1002/anzf.1043

Phipps, W. D., & Vorster, C. (2011). Narrative therapy: A return to the intrapsychic perspective. Journal of Family Psychotherapy, 22(2), 128–147. doi:10.1080/08975353.2011.578036

Saltzman, W. R., Pynoos, R. S., Lester, P., Layne, C. M., & Beardslee, W. R. (2013). Enhancing family resilience through family narrative co-construction. Clinical Child and Family Psychology Review, 16(3), 294–310. doi:10.1007/s10567-013-0142-2