Assignment Help | Using the client family from your Week 3 Practicum Assignment, address in a progress note the following:

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’s 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:

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Treatment modality used and efficacy of the 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 was 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

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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.

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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’s 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.

MODEL ANSWER

Assessing Client Family Progress

Section 1: Progress Note

Demographic Data

Juan Hernandez is a 10-year-old Latino male

Presenting the Problem

The patient mentioned in the case is a 10-year-old child who filed complaints of harassment by the parents. In his report, he stated that he was not comfortable with his parents’ mode of punishment (Bell & Wright, 2015). The social worker who noticed this and later confirmed what was happening was forced to intercede the situation. The penalties… 

Treatment Modality and its Efficacy

The social worker took the parents through a therapy scheme and enlightened them on the most appropriate ways to discipline their child (Salmon, Turner, Taillieu, Fortier & Afifi, 2018). Through the method, the …

Progress towards the Mutual Goals

The procedure was a success, as proved by a comparison between the previous evaluations and the present ones. The child is now jovial as compared to his earlier moods of bitterness and anguish. His self-esteem significantly improved as his parents worked towards building it. Hernandez is grateful for the classes and attributes his parent’s change of behavior towards him to the therapy. Though they let Hernandez make his own decisions, the parents are also actively involved in guiding him in the right path. In addition to telling him about how his behavior …

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Modifications of Treatment

The parents must continue attending the classes, and this is because of development that was evident after comparing the first assessment with the current progress (Salmon et al., 2018). To be specific, the plan informed the parents about the proper ways of disciplining a child in …

Physical Assessment

Vital Signs

Height: 61 inches

Weight: 129lbs

Temp: 36⁰c

Respiratory Rate: 17

Blood Pressure: 120/68

Pulse: 80BPM

Mental Status Exam

The family members frequently take part in a positive parenting initiative, and Hernandez is happy after his engagement in the scheme.

Clinical Impression based on Diagnosis and Symptoms

Besides being marked with confidence, the patient’s speech pattern is steady. Additionally, the bond between the parents and their child has grown significantly.

Relevant Psychosocial Information

Before the intervention of the social worker, the parents’ treatment towards Hernandez was quite harsh. For instance, they would always hit and lock him up in the basement even for a night. On the accounts of both the parents and the child, the social worker confirmed that this kind of abusive treatment had been going on for a long time (Jain, 2015). Nevertheless, taking the parents through the parenting program transformed them…