This week’s first assignment is STEP 3 – Literature Review and Critical Appraisal.

The student will complete the following items and submit a Word doc to the assignment link. 

1. Provide a title that conveys or describes the assignment.
2. Literature Review – Provide the key terms used to guide the search for the evidence and provide at least five (5) summaries of research studies to support the evidence.
3. Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and any gaps in knowledge from the research evidence.
4. References – Cite a minimum of five scholarly references in APA 6th ed format. 4 pages

Expectations

my PICO formatted project question is Question: On a medical-surgical hospital unit (P), how does implementing hourly nursing rounding (I), compared to no scheduled rounding (C), affect patient safety (O), within 6 months of implementing (T)?

SOAP NOTE

This is with the same Family case you used in the Discussion.

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

 PLEASE FOLLOW THE INSTRUCTION BELOW

5 REFERENCES

ZERO PLAGIARISM

earning 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

Assignment 1: (Due in Week 8)

Learning Objectives

Students will:

• Create progress notes
• Create privileged notes
• Justify the inclusion or exclusion of information in progress and privileged

To prepare:

• Reflect on the client family you selected for the Week 3 Practicum Assignment.

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.

Select a client whom you observed or counseled  that suffers from a disorder related to trauma. Then, address the  following in your Practicum Journal:

• Describe the client (without violating HIPAA regulations) and  identify any pertinent history or medical information, including  prescribed medications.
• Using the DSM-5, explain and justify your diagnosis for this client.
• Explain whether any of the therapeutic approaches in this week’s  Learning Resources would be effective with this client. Include expected  outcomes based on these therapeutic approaches. Support your approach  with evidence-based literature.
• Explain any legal and/or ethical implications related to counseling this client.

This paper is done, I only want the third question answered. My take is Cognitive behavioral therapy for PTSD.