Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

·        1-Treatment modality used and efficacy of approach

·        2-Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)

·        3-Modification(s) of the treatment plan that were made based on progress/lack of progress

·        4-Clinical impressions regarding diagnosis and/or symptoms

·        5-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.)

·        6-Safety issues

·        7-Clinical emergencies/actions taken

·        8-Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

·        9-Treatment compliance/lack of compliance

·        10-Clinical consultations

·        11-Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)

·        12-Therapist’s recommendations, including whether the client agreed to the recommendations

·        13-Referrals made/reasons for making referrals

·        14-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)

·        15-Issues related to consent and/or informed consent for treatment

·        16-Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

·        17-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.

 

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