Clinical impressions regarding diagnosis and/or symptoms Relevant psycho social information or changes from original assessment

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 discover able 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.

Sample Solution

ACED ESSAYS