Practicum – Assessing Client Progress assignment

Practicum – Assessing Client Progress assignment

Practicum – Assessing Client Progress assignment

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  • 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.

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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

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