Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format.

Learning Objectives

Students will:
  • 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.)
  • 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.
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