Assignment: Practicum – Assessing Client Progress
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
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
