2024 Brief Structured Follow up Note
[text name="first_name" default="The Client"][select name="gender_ID" value="| (They)| (She)| (He)| (XXXXXX)|"] arrived [select name="on_time" value="on time|5-10 minutes late| more than 10 minutes late|xxxxxx"] for [select name="scheduled_crisis" value="scheduled follow up|crisis|xxxxxx"] session. This session is [select name="placeofservice" cols="40" value=" in person.|via live telehealth with the client at their home in WI.|via live telehealth with the client confirmed to be in WI."] Obtained consent to treat using this modality. This session was medically necessary to address symptoms, improve functioning [checkbox name="preventdecomp" value=" prevent decompensation"][checkbox name="reducesx" value=" reduce symptoms"][checkbox name="maintprogr" value=" maintain progress"][checkbox name="prevhighterneed" value=" prevent necessity for higher level of care"]. [var name="first_name"] reported [checkbox value="increased |decreased |no significant change in |variable"]symptoms of [checkbox value="anxiety |depression |poor impulse control |agitation/restlessness |hypervigilance |fatigue/low energy |trouble staying or falling asleep |intrusive/obsessive thoughts |grief |isolation/loneliness |anger |self-harm |flashbacks |dissociation"]. [textarea name="variable_1" default=""] [var name="first_name"] [select name="indicate_demonstrate" value="indicated and demonstrated|indicated|demonstrated"] [checkbox value="significant |some |maintained |no significant change regarding |ongoing |regression of"] progress in areas of [checkbox value="mindfulness |emotional regulation |assertion of healthy boundaries |utilizing assertive communication skills |use of cognitive coping skills outside of sessions |overall reduced anxiety |overall reduced depression |reduced avoidance of triggers/stressors |increased self care"] since the last session. [textarea name="variable_2" default=""] Session focus: [checkbox name="focus" value="history/background|stressors/coping strategies|affect regulation|family relationships|identity/roles |work/school issues|substance use|trauma|peer relationships |self-image/self-esteem |marital issues|relationship issues|parenting |attachment|sexual issues|grief/loss |health issues|domestic violence|racial identity|cultural identity|boundaries"] Clinical Interventions used [checkbox name="Interventions" value="trauma focused CBT|CBT (cognitive challenging, cognitive refocusing, cognitive reframing)|rapport building|EMDR|DBT|play/art therapy techniques (Note: interactive complexity-use of play/art equipment)|grief processing|psychoeducation regarding symptom-management and skill building|parent education|coping skills|attachment therapy techniques|solution-focused|mindfulness|Family Systems/Dynamics|Internal Family Systems|parts work|Note: interactive complexity-language interpretation"]. [textarea name="variable_3" default=""] Current Functional Impairments [checkbox name="impairments" value="Daily Tasks/Responsibilities|Social|Work/School |Intimate Relationships"]. [textarea name="variable_4" default=""] [checkbox name="medical" value="Medical Necessity of 90837 or Extended Session: |Complex Treatment Issues Addressed|Trauma Issues Addressed Required Time for Containment|Safety Concerns Requiring Additional Time|Prevention of Increasing Frequency of Sessions|Planning of Homework and Skills to Practice Between Sessions|Prevention of Need for Higher Level of Care"]. [textarea name="variable_5" default=""] [checkbox name="homeworkornah" value="Homework:|Between sessions, the client agrees to work on the following: |The client is encouraged to: "][checkbox name="homework" value="Reflect on psychoeducation topics/materials covered in today's session|Engage in journaling/reflective note taking as discussed in session|Create daily routine to encourage self care, behavioral activation, and organization|Consistently commit to daily routine/behavioral activation schedule|Establish healthy boundaries with friends/family using techniques discussed and roleplayed during session|Discuss healthy communication skills with family/friends, as outlined in communication skills work complete in session|Utilize CBT skills (reframing/challenging/replacing negative thoughts)|Engage in self directed exposure therapy/incremental training around specific anxieties as discussed in session|Decrease catastrophic thinking by engaging in behavioral experiments and tracking progress|Engage in mindfulness/stress reduction techniques as practiced in therapy (deep breathing, meditation, guided imagery)|Experiment with at least one new self care activity this week and reflect in journal/planner|Practice distress tolerance skills as rehearsed in therapy|Implement coping skills consistently when dysregulated|Track mood and triggers for mood fluctuations|Follow safety plan if in crisis|Track success and progress toward goals|Devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise"]. [textarea name="variable_6" default=""] [var name="first_name"] would benefit from [checkbox value="continuing psychotherapy|engaging in recovery meetings|continuing recovery meetings|engaging in recovery coaching|continuing recovery coaching|engaging in IOP|engaging in a support group|continuing support group|engaging in family therapy|continuing family therapy|enhanced psychosocial supports|increasing self-care|engaging in psychiatric intervention|continuing psychiatric intervention|engaging in higher level of care"][textarea default=". "rows="2"] Next appointment [select name="scheduling" value="is scheduled for {client_next_appointment_date} at {client_next_appointment_time}.|is scheduled for 1 week out.|is scheduled for 2 weeks out.|is scheduled for 3 weeks out.|is scheduled for 1 month out.|is scheduled for: |to be scheduled by client.|to be scheduled by guardian.|to be scheduled after assessment for higher level of care and completion of recommended treatment.|"][textarea name="ending_text" default=""]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.7, 33 form elements, 47 boilerplate words, 1 text boxes, 8 text areas, 15 checkboxes, 6 drop downs, 3 variables, 136 total clicks
Send Feedback for this SOAPnote