Nursing Journal Entry
art 1: Progress NoteUsing 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 approachProgress 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 progressClinical impressions regarding diagnosis and or symptomsRelevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)Safety issuesClinical emergencies/actions takenMedications used by the patient, even if the nurse psychotherapist was not the one prescribing themTreatment compliance/lack of complianceClinical consultationsCollaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)The therapist’s recommendations, including whether the client agreed to the recommendationsReferrals made/reasons for making referralsTermination/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 treatmentInformation concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reportedInformation reflecting the therapist’s exercise of clinical judgmentNote: Be sure to exclude any information that should not be found in a discoverable progress note.Part 2: Privileged NoteBased 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.
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