, address the following in a progress note (without violating HIPAA regulations): · 1-Treatment modality used and efficacy of approach · 2-Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment planprogress toward goals) · 3-Modification(s) of the treatment plan that were made based on progress/lack of progress · 4-Clinical impressions regarding diagnosis and/or symptoms · 5-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.) · 6-Safety issues · 7-Clinical emergencies/actions taken · 8-Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them) · 9-Treatment compliance/lack of compliance · 10-Clinical consultations · 11-Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.) · 12-Therapists recommendations, including whether the client agreed to the recommendations · 13-Referrals made/reasons for making referrals · 14-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) · 15-Issues related to consent and/or informed consent for treatment · 16-Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported · 17-Information reflecting the therapists exercise of clinical judgment
