Assignment 2: Practicum – Assessing Client Progress week7

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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):


  • 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
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 from the Week 3 Practicum Assignment.

  • The privileged note should 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 progress note.

  • Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.
    • Posted: 4 days ago
    • Due: 
    • Budget: $15
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