Explain why the items you included in the privileged note would not be included in the client family’s progress note
Assignment 2: Practicum – Assessing Client Family Progress Learning Objectives Students will: • 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. 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. Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NURS_6650_Week7_Assignment2_Rubric • Grid View • List View Show Descriptions Quality of Work Submitted: The extent of which work meets the assignned criteria and work reflects graduate level critical and analytic thinking.– Satisfactory 26 (26%) – 30 (30%) Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics. Unsatisfactory 0 (0%) – 25 (25%) Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed. Quality of Work Submitted: The purpose of the paper is clear.– Satisfactory 4 (4%) – 5 (5%) Purpose of the assignment is stated, yet is brief and not descriptive. Unsatisfactory 0 (0%) – 3 (3%) No purpose statement was provided. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to: Understand and interpret the assignment’s key concepts.– Satisfactory 8 (8%) – 10 (10%) Demonstrates a clear understanding of key concepts. Unsatisfactory 0 (0%) – 7 (7%) Shows a lack of understanding of key concepts, deviates from topics. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to: Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.– Satisfactory 16 (16%) – 20 (20%) Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view. Unsatisfactory 0 (0%) – 15 (15%) Includes and integrates specific information from 0 to 1 resoruce to support major points and point of view. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to: Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.– Satisfactory 16 (16%) – 20 (20%) Summarizes information gleaned from sources to support major points, but does not synthesize. Unsatisfactory 0 (0%) – 15 (15%) Rarely or does not interpret, apply, and synthesize concepts, and/or strategies. Written Expression and Formatting Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.– Satisfactory 4 (4%) – 5 (5%) Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 80% of the time. Unsatisfactory 0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time. Written Expression and Formatting English writing standards: Correct grammar, mechanics, and proper punctuation– Satisfactory 3 (3%) – 5 (5%) Contains a few (1-2) grammar, spelling, and punctuation errors. Unsatisfactory 0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Written Expression and Formatting The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.– Satisfactory 3 (3%) – 5 (5%) Contains a few (1-2) APA format errors. Unsatisfactory 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors. Total Points: 100 Name: NURS_6650_Week7_Assignment2_Rubric
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