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 family you selected for the Week 3 Practicum Assignment. (I will upload the week 3 work)

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:

1. 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)
2. Modification(s) of the treatment plan that were made based on progress/lack of progress
3. Clinical impressions regarding diagnosis and or symptoms
4. 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
5. Clinical emergencies/actions taken
6. Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
7. Treatment compliance/lack of compliance
8. Clinical consultations
9. Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
10. The therapist’s recommendations, including whether the client agreed to the recommendations
11. Referrals made/reasons for making referrals
12. 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)
13. Issues related to consent and/or informed consent for treatment
14. Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
15. 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,
1. 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. (see attachment).

In your progress note, address the following:

1. Include items that you would not typically include in a note as part of the clinical record.
2. Explain why the items you included in the privileged note would not be included in the client family’s progress note.
3. Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why. (make it up)

Optional Resources
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.

Required Media
Governors State University (Producer). (2009). Emotionally focused couples therapy [Video file]. Chicago, IL: Author.

The approximate length of this media piece is 115 minutes.

Laureate Education (Producer). (2013b). Hernandez family genogram [Video file]. Baltimore, MD: Author.

Note: The approximate length of this media piece is 3 minutes.

Accessible player
Credit: Provided courtesy of the Laureate International Network of Universities.

Psychotherapy.net. (Producer). (n.d.). Narrative family therapy [Video file].

The approximate length of this media piece is 111 minutes.

Optional Resources
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Boston, MA: Pearson.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.