ESSAY: Practicum – Assessing Client Family Progress

Students will:
Create progress notes
Create privileged notes
Justify the inclusion or exclusion of information in progress and privileged notes
Evaluate preceptor notes
To prepare:
Reflect on the client’s family you selected for the Week 3 Practicum Assignment.
The Assignment
Part 1: Progress Note

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

Treatment modality used and efficacy of the 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 was 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)
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 (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
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 family from the Week 3 Practicum Assignment.

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’s 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.

ANSWER

Assessing Client Family Progress

Section 1: Progress Note

Demographic Data

Juan Hernandez is a 10-year-old Latino male

Presenting the Problem

The patient mentioned in the case is a 10-year-old child who filed complaints of harassment by the parents. In his report, he stated that he was not comfortable with his parents’ mode of punishment (Bell & Wright, 2015). The social worker who noticed this and later confirmed what was happening was forced to intercede the situation. The penalties were so severe to a point they appeared brutal. The social workers decided to handle the issue by taking the family through a therapy. 

Treatment Modality and its Efficacy

The social worker took the parents through a therapy scheme and enlightened them on the most appropriate ways to discipline their child (Salmon, Turner, Taillieu, Fortier & Afifi, 2018). Through the method, the parents understood the behaviors that their children portray at different ages.

Progress towards the Mutual Goals

The procedure was a success, as proved by a comparison between the previous evaluations and the present ones. The child is now jovial as compared to his earlier moods of bitterness and anguish. His self-esteem significantly improved as his parents worked towards building it. Hernandez is grateful for the classes and attributes his parent’s change of behavior towards him to the therapy. Though they let Hernandez make his own decisions, the parents are also actively involved in guiding him in the right path. In addition to telling him about how his behavior affects them, the parents also inform him of his expectations. It is lovely to see the transformation of the child from a bitter to a compassionate person.

Modifications of Treatment The parents must continue attending the classes, and this is because of development that was evident after comparing the first assessment with the current progress (Salmon et al., 2018). To be specific, the plan informed the parents…