Using the provided Client family assessment and Family genogram address in a progress note the following:
Treatment modality used and efficacy of approach
Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
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
Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
The 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 (e.g., 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
Part 2: Privileged Note
Based on the provided readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for the provided Client family assessment and Family genogram
In your progress note, address the following:
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 family’s progress note.
Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.