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Learning Objectives
Students will:
Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
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):
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
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 from the Week 3 Practicum  Assignment.
The privileged note should 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 progress note.
Explain whether your preceptor uses privileged notes, and if so,  describe the type of information he or she might include. If not,  explain why.


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