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.

– be sure to provide a meaningful response to at least two of your peers’ posts by the end of the week. In your responses to your peers, you might offer ways that individuals can mitigate a negative effect of these factors.

– you need to provide evidence to  support your statements.

– APA format.

first peer:  There are many factors that influence todays health care costs inflation effect the healthcare cost because as society grows the amount of people needing healthcare grow as well.  Inflation effects the cost of everything we buy and need, so naturally the cost of healthcare will go up as well.  The changes in population size, age and ethnicity effects the increase cost of care with the amount of people needing healthcare.  Technology of services effects the health care costs, because the cost of the equipment use for diagnosing health issues. We are using less people and more computers to assist with health care, for example at my job we used what we call Caravi, and instead of calling the on call doctor we use a computer.  We have access to a doctor 24 hours a day.  We actually take the computer in a patient room and they are able to talk with a live doctor and see the doctor face to face.  I’m sure the cost for equipment like this effects the cost of health care cost.

Stanhope, M., Lancaster, J., & Stanhope, M. (2018). Foundations for population health in community/public health nursing. St. Louis, MO: Elsevier.

second peer: Health care costs are greatly influenced by many factors. In my opinion the greatest of these factors is the trickle effect of poverty. Impoverished persons seek less preventative care and typically have more health risks than those who are financially stable. Poverty leads to poor health and poor health leads to a less educated population. The community suffers when its residents lack education and quality affordable health care access. Often persons who cannot afford health insurances are forced to seek emergent care at hospitals that cannot turn them away based on their income. Hospitals and physicians write off their expenses and unpaid services. I recently read in an NPR.ORG the article entitled “The Gap Between Rich and Poor Americans’ Health is Widening”. It explains that the gap between the rich and the poor is spreading. This also includes the gap between the rising cost of living and minimum wage. It was likewise noted that in the most recent census quoted in this same article that most American’s felt as though their health was poor. This census compared to race, economic status, and gender differences. It found that those who reported the highest quality of health were rich Caucasian men whereas women and minorities struggled and deteriorated. Recent information also lent to greater studies of segregated neighborhoods and communities. Entire communities swiveled in declining health outcomes.

Neilson, Susie. 2018 June 28. Retrieved from https://www.npr.org/sections/health-shots/2019/06/28/736938334/the-gap-between-rich-and-poor-americans-health-is-widening