Assignment:Assessing Client Progress

Assignment:Assessing Client Progress

Assignment:Assessing Client Progress

Assignment:Assessing Client Progress

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Assignment: Practicum – Assessing Client Progress

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):………THE WEEK 3 ASSIGNMENT IS ATTACHED

· 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

Learning Resources

Required Readings

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.

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

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)

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.

Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

 

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