Address the following in a progress note (without violating HIPAA regulations):
Progress and/or abridgement of advance against the mutually agreed-upon applicant goals (reference the Analysis plan—progress against goals)
Modification(s) of the analysis plan that were fabricated based on progress/lack of progress
Clinical impressions apropos analysis and/or symptoms
Relevant psychosocial advice or changes from aboriginal appraisal (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
Clinical emergencies/actions taken
Medications acclimated by the accommodating (even if the assistant psychotherapist was not the one prescribing them)
Treatment compliance/lack of compliance
Collaboration with alternative professionals (i.e., buzz consultations with physicians, psychiatrists, marriage/family therapists, etc.)
Therapist’s recommendations, including whether the applicant agreed to the recommendations
Referrals made/reasons for authoritative referrals
Termination/issues that are accordant to the abortion action (i.e., applicant abreast of accident of allowance or abnegation of allowance aggregation to pay for connected sessions)
Issues accompanying to accord and/or abreast accord for treatment
Information apropos adolescent corruption and/or ancient or abased developed abuse, including affidavit as to area the corruption was reported
Information absorption the therapist’s exercise of analytic judgment
Note: Be abiding to exclude any advice that should not be begin in a accountable advance note.
Part 2: Advantaged Agenda (10 points)
Research the analogue and purpose of a advantaged psychotherapy note. Prepare a advantaged agenda that you would use to certificate your impressions of ameliorative progress/therapy sessions for your client.
The advantaged agenda should accommodate items that you would not about accommodate in a agenda as allotment of the analytic record.
Explain why the items you included in the advantaged agenda would not be included in the client’s advance note.
Explain whether your adviser uses advantaged notes, and if so, call the blazon of advice he or she ability include. If not, explain why.
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