Learning Objectives

Students will:

· Assess progress for clients receiving psychotherapy

· Differentiate progress notes from privileged notes

· Analyze preceptor’s use of privileged notes

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.

The benchmark assesses the following competency:

Benchmark: 5.1. Understand the human experience across the health-illness continuum.

Research the health-illness continuum and its relevance to patient care. In a 750-1,000 word paper, discuss the relevance of the continuum to patient care and present a perspective of your current state of health in relation to the wellness spectrum. Include the following:

1. Examine the health-illness continuum and discuss why this perspective is important to consider in relation to health and the human experience when caring for patients.
2. Reflect on your overall state of health. Discuss what behaviors support or detract from your health and well-being. Explain where you currently fall on the health-illness continuum.
3. Discuss the options and resources available to you to help you move toward wellness on the health-illness spectrum. Describe how these would assist in moving you toward wellness (managing a chronic disease, recovering from an illness, self-actualization, etc.).

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

  

Format: APA style essay structured  with appropriate grammar, sentence and paragraph composition, spelling, punctuation, and logical, clear essay development (including introduction and conclusion). Paper length 1-2 pages  excluding cover and reference page. Must have a minimum of three references and references must be within 5 years. 

Content: You will address the topics below:

1. Complete a short nursing leadership paper that describes leadership and manager competencies & styles. 

Please provide plagiarism check 

DUE DATE: 1/18/2020

at least 2 references in each peer responses! 

  

Utilizing a portfolio showcases a nurse’s accomplishments, both academically and professionally. There are many advantages to using a portfolio. It can allow nurses to help identify their strengths and areas that need further development. It helps to keep all documents that are necessary for re-certifications and evaluations organized and together (Cope & Murray, 2018). There are two types of professional portfolios: a growth and development portfolio and best work portfolio (Cope &Murray, 2018). A growth and development is used for nurses to track their growth and development and is not used by anyone else. A best work portfolio is meant to be used for and by potential employers to show the growth in their career and academics.

 

Placing academic successes into a portfolio such as academic transcripts, allows for employers or potential employers to see your achievements. Something that I have utilized in addition to putting transcripts into my portfolio was adding letters of recommendation from my clinical instructors from nursing school. This helped to show potential employers my abilities both in a classroom as well in a clinical nursing setting. Others could put in memberships for academic organizations, such as honor society groups. This would be accurate for those in a masters program or in a graduate program. Another type of academic achievement that could be placed into my portfolio would be any continuing education such as certificates showing a completion of a course towards the maintenance of certifications.