In this assignment, you will complete psychotherapy counseling note of an adult/older adult. You can use a patient you’ve seen in clinical or someone in your personal life. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point.
At a minimum, 4 scholarly references should be included and cited in APA 7th Edition formatting. The references page should be set up similar to papers that are in full APA 7th edition formatting.
Here is the rubric for grading:
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Subjective Data
25 pts
Exemplary Exceeds Expectations
Client description was 1-2 sentences in length. Includes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in systematic, organized manner consistently.
20 pts
Advanced Meets Expectations
Includes most subjective data with omission of two minor details or one major detail. Most data is presented in systematic, organized manner.
15 pts
Intermediate Needs Improvement
Includes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.
10 pts
Novice Inadequate
Data is not presented in a systematic, organized manner. Lacking most or all subjective data.
0 pts
Incomplete
Assignment not completed or submitted late.
25 pts
This criterion is linked to a Learning Outcome Objective Data
25 pts
Exemplary Exceeds Expectations
Client description was 1-2 sentences in length. Includes all relevant subjective data necessary for differentiation of the client’s problem using the OLDCART and/or SIGECAPS Mnemonics.
20 pts
Advanced Meets Expectations
Objective data is complete and presented in an organized manner most of the time. Appearance, behavior, eye contact, speech, mood, affect, thought process, thought content, perceptual abnormalities, cognition, orientation, memory, insight, and judgment are addressed and 1-2 are missing.
15 pts
Intermediate Needs Improvement
Objective data is not complete or is not presented in an organized manner. Appearance, behavior, eye contact, speech, mood, affect, thought process, thought content, perceptual abnormalities, cognition, orientation, memory, insight, and judgment are addressed and 3 or more are missing.
10 pts
Novice Inadequate
Objective data is not complete and is not presented in an organized manner. Lacking most or all objective data.
0 pts
Incomplete
Assignment not completed or submitted late.
25 pts
This criterion is linked to a Learning Outcome Assessment
25 pts
Exemplary Exceeds Expectations
Assessment, includes progress note- 5 or more sentences, or notation that it is not applicable as it is an initial visit, Diagnosis-current and rule-out, Homework: 2-3 sentences with plan or notation why it is not applicable to this client, need for follow up, CPT code that is applicable for session that are complete and appropriate to client. ICD code that is applicable for session is complete and appropriate for session.
20 pts
Advanced Meets Expectations
Assessment, includes progress note- minimal 2-5 sentences or notation that it is not applicable as it is an initial visit, Diagnosis- current and rule-out, Homework 1-2 sentences with plan or notation why it is not applicable to this client, need for follow up, CPT code, but some of the content is not appropriate for client. ICD code that is applicable for session is complete and appropriate for session.
15 pts
Intermediate Needs Improvement
Assessment, homework, needs for follow up , CPT code, ICD code, diagnosis (if appropriate), is not complete but is appropriate.
10 pts
Novice Inadequate
Assessment, including diagnosis (if appropriate), is not complete or appropriate, or it is not evident.
0 pts
Incomplete
Assignment not completed. Submits assignment late.
25 pts
This criterion is linked to a Learning Outcome Professional Application
15 pts
Exemplary Exceeds Expectations
Psychotherapy note incorporates four evidence-based practice articles.
10 pts
Advanced Meets Expectations
Psychotherapy note incorporates three evidence-based practice articles.
7 pts
Intermediate Needs Improvement
Psychotherapy note incorporates two evidence-based practice articles.
5 pts
Novice Inadequate
Psychotherapy note Does not include evidence-based practice article but has one advanced practice article or does not include evidence-based practice article or advanced practice article.
0 pts
Incomplete
Assignment not completed.
15 pts
This criterion is linked to a Learning Outcome Organization, APA, Grammar, and Spelling
10 pts
Exemplary Exceeds Expectations
Well organized content that is clear and concise. Correct APA formatting with no errors. The writer correctly identifies reading audience, as demonstrated by appropriate language (avoids jargon and simplifies complex concepts appropriately). There are no spelling, punctuation, or word-usage errors.
8 pts
Advanced Meets Expectations
Organized content that is informative and supportive of purpose. Correct and consistent APA formatting of references, and cites all references used. No more than one to two unique APA errors. There are minimal to no grammar, punctuation, or word-usage errors.
7 pts
Intermediate Needs Improvement
Poor organization and flow of ideas may distract from the content. Three to four unique APA formatting errors. The writer occasionally uses awkward sentence construction or overuses/inappropriately uses complex sentence structure. Problems with word usage (evidence of incorrect use of thesaurus) and punctuation persist, often causing some difficulties with grammar. Some words, transitional phrases, and conjunctions are overused. Multiple grammar, punctuation, or word usage errors.
6 pts
Novice Inadequate
Illogical flow of ideas. Many APA formatting errors, or no attempt to format in APA. The writer struggles with limited vocabulary and has difficulty conveying meaning–noting just the broadest of meanings. Grammar and punctuation are consistently incorrect. Spelling errors are numerous. Submits assignment late.
0 pts
Incomplete
Assignment not completed.
10 pts
Total Points: 100
Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!
To complete your psychotherapy counseling note for an adult or older adult, follow these structured steps to meet the assignment’s criteria and expectations.
1. Introduction: Client Description
- Start with a Brief Client Overview: Begin your note by providing a 1-2 sentence description of the client. This should include the client’s age, gender, relevant background information, and presenting issue(s) they are seeking help for.
- Contextualize the Subjective Data: Ensure the subjective data is gathered directly from the client’s own words. This includes their chief complaint, history of the presenting problem, and any relevant details such as duration, severity, and triggers.
2. Subjective Data
- Gather All Necessary Information: Include detailed subjective data about the client’s mental and emotional state. Refer to course texts and mnemonics like OLDCART (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment) or SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation or retardation, Suicidal thoughts) to structure this data.
- Ensure Clarity and Organization: Present the data in a systematic and organized manner, using bullet points or a clear paragraph structure for easy reading.
3. Objective Data
- Observation of Client’s Appearance and Behavior: Note their physical appearance, eye contact, posture, and any unusual behaviors.
- Assess Mental Status: Include observations on speech, mood, affect, thought process, thought content, and perception. Utilize standard clinical assessments to assess cognition, memory, orientation, insight, and judgment.
- Document Any Perceptual Abnormalities: If there are any indications of perceptual abnormalities, such as hallucinations or delusions, document these findings.
4. Assessment
- Include a Progress Note: Write a comprehensive 2-5 sentence progress note based on the session. Reflect on the client’s current mental state, their responses to therapy, and their engagement with the treatment process.
- Diagnosis and Rule-Out: Include the current diagnosis if applicable, and any possible diagnoses that you are considering for rule-out purposes. Provide relevant ICD codes for the session.
- Homework/Plan for Follow-Up: Indicate whether homework or tasks have been assigned to the client and describe these briefly. If there are no specific tasks, note why this is the case.
- CPT Code: Ensure the appropriate CPT code for the session is included, reflecting the type of therapy provided (individual, group, etc.).
5. Professional Application
- Incorporate Evidence-Based Practices: Your note should reference at least four scholarly, evidence-based practice articles related to psychotherapy or counseling techniques. Use these references to inform your assessment and interventions, ensuring the application of current therapeutic practices.
6. APA 7th Edition Formatting
- Correct APA Formatting: Follow the APA 7th Edition guidelines for citations, references, and overall paper structure. Ensure that your reference page is formatted correctly and includes at least 4 scholarly references.
- Clear, Concise Writing: Ensure that your note is well-organized and free of jargon. The content should be clear, concise, and accessible, with correct grammar, spelling, and punctuation.
7. Editing and Finalizing the Note
- Proofread for Organization and Clarity: Make sure the content flows logically and that there is a clear connection between subjective and objective data, as well as between the assessment and treatment plan.
- Review APA Formatting: Double-check the APA format, especially in-text citations and reference lists, to ensure full compliance with APA 7th edition rules.
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