Client Progress and Privileged Notes

Client Progress and Privileged Notes

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. verbiage from week three pt uploaded

The 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:

• 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)
• 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
• 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
• The 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 (e.g., 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 family from the Week 3 Practicum Assignment.

In your progress note, address the following:

• 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 family’s progress note.
• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.

SAMPLE ANSWER

Client Progress and Privileged Notes

Part 1: Progress Note

Treatment Modality:   Matthew was involved in counseling sessions to understand that failure is normal. The approach applied Self-efficacy theory (Cohn, 2014).

Progress towards Client Goals: The client has been keen on engaging in the counseling sessions. He relates well with his mother and wife who are usually present during the family therapy session (Freedman, 2014).

Clinical Impressions: Physical assessment of Matthew reveals that his racing heart is slowing down. This shows that his condition is reducing progressively.

Psychosocial Changes: Matthew’s family has relocated to a suburban area. Moreover, their children have been admitted to boarding schools. Jennifer reveals that these actions are to ensure that she has more attention and support for her husband (Er, 2015).

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Safety issues: Matthew does not present any safety problems. He is friendly and social to people around him.

Clinical Emergencies Taken: No clinical emergencies have been taken as the client’s condition has not worsened.

Treatment compliance: The patient is compliant to the treatment procedure and follows the development rules.

Therapist’s Recommendations: It was recommended that the patient should increase the number of sessions in a week to enhance proper evaluation of the therapy’s effectiveness. The client showed willingness to follow the recommendation.

Referrals made/reasons for making referrals: The patient was referred to a cardiologist to have CT Scans for his heart to have an accurate understanding of its racing.

Termination Issues:The client does not have any termination-related issues. The counseling sessions continue without hindrances.

Informed Consent for Treatment: The patient was provided with suitable information to enable him make an informed consent. This act was in line with the ethical concerns of the facility.

Information concerning Abuse:Matthew does not present any form of child or dependent adult abuseat any place.

Part 2: Privileged Note

Client Progress and Privileged Notes

Reasons for Exclusion of the Information from Progress Note

In healthcare law, privilege gives the patient the right to prohibit the therapist from disclosing the information. Therefore, the therapist has to create a protection of the patient’s confidential issues. In Matthew’s case, privileged information may refer to what he says in a private session. Since the family therapy also involves his mother and wife, the information he provides during a private session are not to be shared with anyone (Simon &Willick, 2016).

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Preceptor’s Perspective on Privilege Note Inclusion

The preceptor uses privilege notes. According to her, information that she would include in the notes are information that is based on her observation.  She also reveals that hypotheses are supposed to be kept confidential. Moreover, she also reveals that the questions that she is asked about the client or session need to be provided in the privilege note.  In addition, she advises that any thoughts that may be generated from the therapy should also be included in a privileged note.

References

Cohn, A. S. (2014). Romeo and Julius: A narrative therapy intervention for sexual-minority

couples. Journal of Family Psychotherapy, 25(1), 73–77.

Er, I. (2015). Diagnosis and management of generalized anxiety disorder and panic

disorder in adults. Am Fam Physician, 91(9), 617-624.

Freedman, J. (2014). Witnessing and positioning: Structuring narrative therapy with families and

couples. Australian & New Zealand Journal of Family Therapy, 35(1), 20–30.

Silva, J. A. M. D., Siegmund, G., & Bredemeier, J. (2015). Crisis interventions in online

psychological counseling. Trends in Psychiatry and Psychotherapy, 37(4), 171-182.

Simon, R. A., & Willick, D. H. (2016). Therapeutic privilege and custody evaluations: Discovery

of treatment records. Family Court Review, 54(1), 51-60.

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