· 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.
Part 1: Progress Note
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):………THE WEEK 3 ASSIGNMENT IS ATTACHED
· 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
· 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
· 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
· 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
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)