Practicum – Assessing Client Progress assignment

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