Assessing Client Progress

Assignment: Practicum ? Assessing Client ProgressTo prepare:ú Reflect on the client you selected for the Week 3 Practicum Assignment.ú Review the Cameron and Turtle-Song (2002) article in this week?s LearningResources for guidance on writing case notes using the SOAP format.The AssignmentPart 1: Progress NoteUsing the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):???THE WEEK 3 ASSIGNMENT IS ATTACHEDú Treatment modality used and efficacy of approachú Progress and/or lack of progress toward the mutually agreed-upon client goals(reference the Treatment plan?progress toward goals)ú Modification(s) of the treatment plan that were made based on progress/lack ofprogressú Clinical impressions regarding diagnosis and/or symptomsú Relevant psychosocial information or changes from original assessment (i.e.,marriage, separation/divorce, new relationships, move to a newhouse/apartment, change of job, etc.)ú Safety issuesú Clinical emergencies/actions takenú Medications used by the patient (even if the nurse psychotherapist was not theone prescribing them)ú Treatment compliance/lack of complianceú Clinical consultationsú Collaboration with other professionals (i.e., phone consultations with physicians,psychiatrists, marriage/family therapists, etc.)ú Therapist?s recommendations, including whether the client agreed to therecommendationsú Referrals made/reasons for making referralsú Termination/issues that are relevant to the termination process (i.e., clientinformed of loss of insurance or refusal of insurance company to pay forcontinued sessions)ú Issues related to consent and/or informed consent for treatmentú Information concerning child abuse, and/or elder or dependent adult abuse,including documentation as to where the abuse was reportedú Information reflecting the therapist?s exercise of clinical judgmentLearning ResourcesRequired ReadingsWheeler, 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? ÿÿÿÿÿ(pp. 238?242)Chapter ÿÿÿÿÿ9, ?Interpersonal Psychotherapy? (pp. 347?368)American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.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:10.1037/12353-048Cameron, 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)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__krLZ4U.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 MediaSommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.

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