Practicum – Assessing Client Progress

Assignment Instructions. Please read carefully to the end before starting

Assignment 2: Practicum – Assessing Client Progress

To prepare:

· Reflect on the client you selected for the Week 3 (See the attached case study for client selected in 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 (See attached resource).

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): (See sample paper)

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.)

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, 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.

Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

References

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

· Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)

· Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: You will access this text from the Walden Library databases.

Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048

Note: You will access this resource from the Walden Library databases.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

Note: You will access this article from the Walden Library databases.

Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4

U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/

Required Media

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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Practicum – Assessing Client Progress