Practicum – Assessing Client Progress assignment
Practicum – Assessing Client Progress assignment
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
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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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