Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
· 1-Treatment modality used and efficacy of approach
· 2-Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
· 3-Modification(s) of the treatment plan that were made based on progress/lack of progress
· 4-Clinical impressions regarding diagnosis and/or symptoms
· 5-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.)
· 6-Safety issues
· 7-Clinical emergencies/actions taken
· 8-Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
· 9-Treatment compliance/lack of compliance
· 10-Clinical consultations
· 11-Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
· 12-Therapist’s recommendations, including whether the client agreed to the recommendations
· 13-Referrals made/reasons for making referrals
· 14-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)
· 15-Issues related to consent and/or informed consent for treatment
· 16-Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
· 17-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.
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