Psychiatry
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[link url="https://www.soapnote.org" memo="Dx List"]
Expected Length of tx: [textarea] 12 - 16 Sessions (Approx. 3 - 4 Months)
17 - 32 Sessions (Approx. 5 - 8 Months)
33 - 48 Sessions (Approx. 9 - 12 Months)
More than 48 Sessions (12 months +)
freq of tx
Weekly
Bi-weekly
Other"[/textarea]
--
tx PLAN
[textarea]# Problem 1:
## Baseline --
## GOAL --
# Problem 2:
# Problem 3:
## GOAL --
# Interventions for Problem 1:
# Interventions for Problem 2:
# Interventions for Problem 3:
Start: <date>
freq weekly[/textarea]
Tx Plan:
Will [textarea] incr
Improve
Learn
[/textarea] [textarea]Better
Accept
Manage
Tolerate [/textarea] [textarea] Effective Parenting Skills
Problem-Solving/Decision Making Techniques
How I Come Across - Others
Improve Friendships
Relax [/textarea] [textarea] Loss/Death
Health
Pain
Temper
Time
Mistakes
Others’ Mistakes[/textarea]
Control [textarea] Alcohol Use
Eating / Weight
Use Of Drugs[/textarea] [textarea] Not React So Emotionally
Not Take Disappointment So Hard
Express Self Assertively
Be Optimistic
Adopt Healthier Attitude
Allow Self - Express Feelings[/textarea] [textarea] Adjust Better -
Past Incident
Recent Change / Incident[/textarea]
Receive [textarea] med Help[/textarea]
Discuss [textarea] Thoughts Of
Harming Others
Harming Self
Talk Out Pending Decision[/textarea]
incr. / Improve [textarea] Conversation Skills
Communication w/ Spouse/Children/Friends/Coworkers/Others
Self-Awareness
Sexual Relationship
Sleep
Pleasurable Activities
Think Positively
Take Initiative[/textarea] Decr. [textarea] Feel
Less
Efforts - Be Perfect
Procrastination
Family Difficulties
Fear(S)
Job Difficulties
Sensitivity - Criticism
Uncomfortable Thoughts
Worry
Self-Confident
Depressed
Guilt
Change Habit [/textarea]
Evidenced By [textarea] Self Report
Staff Observation
tracking Tool
Appointment Attendance[/textarea]
Objectives Of Tx: [textarea]Reduce Depression
bx Activation
Assess For Unhealthy Thinking & Implement Cognitive Restructuring
incr Social Support
med Evaluation & Compliance [/textarea]
Reduce Anxiety - Relaxation training [textarea] Pmr
Cognitive Restructure
Yoga
Exercise
incr Self Esteem - + Asset Search
Perceived Vs Ideal Self
Try New things
incr Socialization
Clarify & Strengthen Boundaries [/textarea]
-Psychoeducation- [textarea] Recommend Boundaries By Henry Cloud & John Townsend
Assertiveness training
Improve Self Care-Self Care Assessment
Daily Shower
Sleep Hygiene
Buy things For self [/textarea]
elim Substance Abuse
[textarea]- Motivational Interviewing
Participate In Support Group [textarea] Aa
Na [/textarea]
elim Self Harm
[textarea] Self Injury-stopping Pain Worksheets
Harm Reduction
DBT[/textarea] Mi [/textarea] [textarea] incr Self-Worth
Improve Communication Skills–Psychoeducation—Gottman Materials
Speaker-Listener Exercises
Role Play In Session
incr Assertiveness-incr Communication training [/textarea]
Process Grief & Loss-Appointments w/ Grief [textarea] Journaling
Share Pictures
Memories
Psychoeducational Materials
Recommend Support Groups [/textarea]
Reduce Traumatic Responses - [textarea] Raise Awareness Of Triggers
Relaxation training
Exposure Tx
Emdr[/textarea]
Evaluate Marital Status [textarea] (Relationship Status)-Sound Relationship House By Gottman
Psychoeducation—Recommend Gottman Materials & Classes; Evaluate Pros & Cons
Psychoeduction On Abusive Relationships
Improve Relationship w/ Spouse–Psychoeducation--Gottman Materials
Love Languages By Gary Chapman
Date Nights
Gottman Interventions
Include Listene Exercises
Recovery From Fight
How - Compromise[/textarea]
Improve Sleep Quality-Sleep Hygiene Habits Include [textarea] Hot Bath / Shower
No Electronics
Complete Sleep Study
Utilize Cpap When Required
med Compliance [/textarea]Relaxation
Improve Parenting Skills-Love & Logic training [textarea] Handouts
& Psychoeducation
Love Languages For Children
Education On Developmental Stages[/textarea].
By [textarea] Practicing
Taking
Using[/textarea] [textarea] Behavior Modification
CBT
Communication Skills
Coping Skills
Dbt
Family/Couples
Grief Work
Mindfulness
Motivational Interviewing
Parenting Skills
+ Reinforcement
Problem Solving
Psychoeducation
Reality test
Reframing
Stress Reduction
Structural Family Tx
Solution Focused
Supportive Tx [/textarea]
Status Of Problem/Focus Of Tx: [textarea] New
Improved
Deteriorated
No Change
Problem Resolved[/textarea]
[textarea]Currently Endorses Following sx:[/textarea]
[link url="[/textarea] [textarea] # Problem
## Baseline -- intrusive thoughts associated w/ traumatic event, daily.
## GOAL -- elim intrusive thoughts of traumatic event from daily - zero/per week.
## Baseline -- social withdrawal & isolation, daily.
## GOAL -- elim social isolation from daily - 5-6x/per night, evidenced by social interactions w/ peers from 0x/per week - 3-4x/per week.
## has not been able - come - terms emotionally w/ multiple traumatic events, evidenced by emotional blunting, intrusive thoughts, paranoia, interpersonal conflict, & emotional lability.
## GOAL -- assist in emotional processing through 1x weekly psychotherapy
## Baseline -- sleep impairment, such that sleeps 3-4 hours/per night; daily.
## GOAL -- improve sleep capacity, from 3-4 hours/per night on daily basis - 7-8 hours/per night, 5-6x/per night. [/textarea]
GOALS & OBJECTIVES
Goals: [textarea] Short Term Goals:
Long Term Goals:[/textarea]
sx MANAGEMENT [textarea] sx Reduction
incr ability
elim intrusive thoughts of traumatic event from daily - zero per week
reduce [/textarea]
OBJECTIVES: [textarea] will:
what going - do w/freq):
incr
initiate
elim
independently
decr sx of [/textarea] [textarea] utilize peer support
Reduce Social Anxiety by initiating # social interactions per wk observed by
daily
3-5x/wk
-
least
independently identify
will meet all goals by 80% / better - be discharged - community w/ referral if needed. [/textarea]
[textarea]over next 6 months
per week observed by
TARGET DATE PLAN - BE REVIEWED:
freq/# of Sessions:
tx Plan Review Date: [/textarea] [textarea] Goals - be reviewed three months from today’s date, & needed.
Date Achieved:
Strengths:
Blocks that Prevent Success: [/textarea]
Presenting Problem
Presenting Target sx (Include Duration)
[textarea]ICD 10 dx Code(s):
DSM IV TR
Axis I --
Axis II --
Axis III --
Axis IV --
Problems w/ primary support group
Economic problems
Health related problems
Housing problems
Problems related - legal/criminal system
Occupational problems
Problems related - social environment/school
Other psychosocial & environmental problems
Psychosocial Factors:
Axis V (GAF) -- current Past year [/textarea]
DSM 5
ASSESSMENT OF NEEDS
[textarea]Legal Issues:
Cultural/Religious Needs: [
Identified Problem / Need: [
Long Term Goal:
Other Agencies/Individuals Involved
Agency/Individual:
Contact Information:
Guardian/Family Input
Family Vision
tx Needed After Discharge:
decrease
decrease sx of
demonstrate
eliminate
eliminate intrusive thoughts of traumatic event from daily - zero/per week.
elim social isolation from daily - 56x/per night, evidenced by social interactions w/ peers from 0x/per week - 34x/per week. Identify BarriersimplementimproveImprove ability toimprove functional capacity associated withimprove selfesteem that has been negatively impacted byimprove sleep capacity, from 34 hours/per night on daily basis - 78 hours/per night, 56x/per night.Improve Social Skillsincreaseincrease abilityIncrease Coping SkillsIncrease Sense Of Identity & SelfEfficacy, Resulting In Greater Independence.incr Commitment - Her Life
Increase stress managment skillsindependentlyinitiaterebuild & feel healthier about reduceSymptom Management: Maintain Management Of Panic sx. sx Reduction
Estimated termination date:
After Care Plans:
What expecting of services:
support
ideas
place - process experiences
Improve ability -
appears motivated - initiate in therapeutic tx
What willing - contribute (motivation)
regular attendance
participation
homework assignments
appears - be motivated - work towards therapeutic tx goals
Stated Goal of :
Improve Social Skills
incr Coping Skills
incr stress managment skills
tx planning has met tx goals & level of functioning presents that can safely be discharged from therapy. has progressed in therapy goals - level that session freq will be reduced.level of functioning & incr risk - self has indicated that will be referred - higher level of tx.level of functioning has deteriorated & presents incr risk of self harm & / deterioration of daily living skills - justify incr in freq of therapy sessions.Continue Psychotherapy w/ Focus On Distress Tolerance & Improving Future CopingContinue Psychotherapy w/ Focus On Improving Communications Between Members Of FamilyContinue Psychotherapy w/ Focus On Improving Self-Image & Self-EfficacyContinue Psychotherapy w/ Focus On Social Skills & Relational FunctioningContinue w/ Adjunctive Couples TherapyContinue w/ Adjunctive Family TherapyContinue w/ Couples Therapy w/ Focus On Expressing EmotionsContinued Sessions Indicated Due - Risk & Thus Continued Sessions Needed - Prevent Deterioration In FunctioningReviewed developmental, family, psychosocial, psychiatric, medical, academic, & occupational hxReviewed sx & functioning in life domains.Interventions Focused On Labeling Maladaptive Defenses Understanding EtiologiesDischargeAs This Therapist ExploredBuildingBasedCollateral ParticipantsCollateral ConsultCollaborationReviewed DevelopmentalUnrealistic ExpectationsUpdateFamily Will Return For Family Therapy In Two WeeksCouple Will Return For Couples Therapy In Two Weeks
Continued sessions indicated due - risk & thus continued sessions needed - prevent deterioration in functioning. has progressed in therapy goals - level that session freq will be reduced. has met tx goals & level of functioning presents that can safely be discharged from therapy. level of functioning has deteriorated & presents incr risk of self harm & / deterioration of daily living skills - justify & incr in freq of therapy sessions. level of functioning & incr risk - self has indicated that will be referred - higher level of tx. has made no progress.
will return for individual psychotherapy in one week.Family will return for family therapy in two weeks.Couple will return for couples therapy in two weeks.Continue psychotherapy w/ focus on distress tolerance & improving future coping.Continue psychotherapy w/ focus on social skills & relational functioning.Continue psychotherapy w/ focus on improving communications between members of family.Continue psychotherapy w/ focus on improving self-image & self-efficacy.Continue w/ couples therapy w/ focus on expressing emotions.Continue w/ adjunctive couples therapy.Continue w/ adjunctive family therapy.
Continue w/ couples therapy w/ focus on expressing emotions.Continue psychotherapy w/ focus on distress tolerance & improving future coping.Continue psychotherapy w/ focus on improving self-image & self-efficacy.Continue psychotherapy w/ focus on social skills & relational functioning.Continue psychotherapy w/ focus on improving communications between members of family.
Partial Care
DD Services
Substance Abuse tx/Counseling
Safe Housing/Domestic Violence
smoking cessation
*What motivation & readiness - engage in tx: (action-oriented, contemplative, etc.)*
Precontemplation: Lack of insight/awareness re: self, needs, recovery, alternative environments/exposure - more adaptive living / lack of understanding re: rehabilitation process.
CBRS:
Functional areas - be addressed (i.e. Psychiatric, Medical, Social/Family, Legal, Educational, Financial, Housing):
Contemplative: Aware, Motivated, & Open - Change
Action: Taking direct action toward achieving goals
Maintenance: Successfully avoiding former bx & keeping up new bx. Assured that will be able - continue - change.
Termination: Members have zero temptation & 100% self-efficacy. sure will NOT return - old, unhealthy habits way of coping.
What capacity - engage in services: (age specific, demonstrated cognitive capacity - benefit from services):
What skills & knowledge needed for - achieve rehabilitation goals:
CM: Specific social, bx, / medical services need assistc. in linking. Include narrative thinking medical necessity (Housing, medical care, coordinating transportation, legal matters, childcare, employment, bx healthcare, educational/continuing education, public assistc.):
If determination has been made we unable - serve this , make appropriate referrals - other agencies - meet identified needs:
CBRS: Functional areas - be addressed (i.e. Psychiatric, Medical, Social/Family, Legal, Educational, Financial, Housing)
med Management – Quarterly / needed for 1 year
CBRS – Recommended number of hours per week:
CM – Recommended number of hours per week:
Functional Deficits - Be Addressed in CBRS & // CM
*LEVEL OF CARE RECOMMENDED*
Psychotherapy (Individual, Family & // Group) – Weekly / needed
tx Recommendations & Medical Necessity:
* tx recommendations listed below medically necessary, represent least restrictive alternative & can reasonably be expected - improve / maintain condition / prevent further regression.
Due - signs, sx & external factors tx needs :*
High
Moderate
Low
*Expected duration of service(s)*
1-3 months
4-6 months
7-9 months
10-12 months
Other
Promote [textarea] healthy behavior
Effectively manage
chronic illness[textarea]
[textarea]elim
barriers - tx
incr
service coordination & provider collaboration
Contain
health care costs[/textarea]
Environmental Needs [textarea] physical
bx
psychosocial [/textarea]
Proactive identification, outreach, & assessment - intervene early possible along wellness/ disease continuum.
Beacon Emotional Problems List: [textarea] Feeling down, depressed / hopeless
Trouble falling / staying asleep, / sleeping too much
Feeling tired / having little energy
Poor appetite / overeating
Feeling bad about self —/ that failure / have letyourself / your family down
Trouble concentrating on things, such reading newspaper orwatching television
Moving / speaking so slowly that other people could have noticed;/ opposite—being so fidgety / restless that have beenmoving around lot more than usual
Feeling nervous, anxious, on edge / worrying lot about differentthings
Muscle tension, aches / soreness
Becoming easily annoyed / irritable
Having anxiety attack—suddenly feeling fear / panic
Feeling that can’t control what / how much eat
Making self vomit
Using alcohol / drugs, / being high from alcohol / drugs, / hungover from alcohol / drugs while working, going - school, ortaking care of children / other responsibilities
Missing / being late for work, school / other activities because youwere drinking / hung over
Thinking that would be better off dead / hurting self insome way* [/textarea]
If checked box should talk about your feelings w/ your healthcare provider soon possible There help available
Physical Activity Checklist [textarea] day(s)
How Long
Moderate:
Gardening
Using manual wheelchair
Yoga / stretching
Slow biking
Walking up stairs
Dancing
Brisk walking
Water aerobics
Vigorous:
Aerobic dance Squats / sit ups
Jump rope Lift weights
Race walking/running Fast biking
Soccer Swimming laps[/textarea] [textarea] decr
elim intrusive thoughts of traumatic event from daily - zero/per week.
elim social isolation from daily - 5-6x/per night, evidenced by social interactions w/ peers from 0x/per week - 3-4x/per week.
improve sleep capacity, from 3-4 hours/per night on daily basis - 7-8 hours/per night, 5-6x/per night.
incr Sense Of Identity & Self-Efficacy, Resulting In Greater Independence.
incr Commitment - Life
improve functional capacity associated w/
improve self-esteem that has been negatively impacted by
rebuild & feel healthier about
sx Management: Maintain Management Of Panic sx. [/textarea]
LONG-TERM GOALS: [textarea] elim/reduce negative impact of trauma sx on social, occupational, & family functioning.
Return - level of psych functioning prior - exposure - trauma.
Extinction of intrusive recollections, avoidance, intense arousal, & disinterest in activities/relationships.
Thinks about / openly discusses traumatic event w/ others without experiencing psychological / physiological distress.
No longer avoids persons, places, activities, & objects that reminiscent of traumatic events. [/textarea]
SHORT-TERM OBJECTIVES [textarea] Describe in much detail comfort allows nature & hx of PTSD sx.
Acknowledge any substance use.
Verbalize any sx of depression, including any suicidal thoughts.
Recall traumatic event without becoming overwhelmed w/ negative emotions.
Return - pretrauma level of functioning without avoiding people, places, thoughts, / feelings associated w/ traumatic event.
Display full range of emotions without experiencing loss of control.
Develop & demonstrate coping skills - reduce mood swings & control impulses.
Develop & implement effective coping skills - carry out normal responsibilities, participate constructively in relationships, & bring addiction under control.
Terminate dichotomous thinking, unmanaged anger, &// fear of abandonment.
Reduce freq of self-damaging bx (e.g., substance abuse, reckless driving, sexual acting out, binge eating, / suicidal bx).
Develop healthy & rewarding interpersonal relationships.
Resolve emotional effects of past trauma, & terminate its negative impact on current behavior.
Terminate destructive bx that serve - maintain escape & denial, while implementing bx that promote healing, acceptance of past events, & responsible living.
Elevate self-esteem.
Develop consistent, positive self-image.
Establish inward sense of self-worth, confidence, & competence.
Interact socially without undue distress / disability.
Interact normally w/ friends & family without irrational fears / intrusive thoughts that control behavior.[/textarea] [textarea] in pre-contemplation phase related - ISSUE(S). Offer factual information about health & ISSUE(S). Explore events that brought - tx (impact of ISSUE(S) (i.e. BMI, diabetes, / substance use & health). Explore results of previous efforts - improve health & role of ISSUE(S). Explore pros & cons of improving health & ISSUE(S). [/textarea]
Items wnl/Completed/Improved. [textarea] - be complete on date specified.
Will review in 3 months of specified date, / PRN - ensure item does not need - be readdressed:
- be wnl on date specified. Will review in 3 months of specified date, / PRN - ensure item does not need - be readdressed: [/textarea] [textarea] in contemplation phase related - ISSUE(S).
Explore sense of self-efficacy - reduce health sx. Explore expectations about change - what role of ISSUE(S) (i.e. BMI, diabetes, / substance use & health) on health sx? Summarize self-motivational statements for change in ISSUE(S). Continue exploration of pros & cons of improving health & ISSUE(S).
in determination phase related - ISSUE(S). Offer menu of options for addressing health sx & ISSUE(S) (i.e. BMI, diabetes, / substance use & health). Help identify pros & cons of various change options. Identify & lower barriers - change. Help enlist social/peer support. Encourage - publicly announce plans - change.
in action phase related - ISSUE(S). Support realistic view of change through small steps. Identify high-risk situations for ISSUE(S) (i.e. BMI, diabetes, / substance use & health) & impact of use on health functioning. Develop coping strategies, Assist in finding new reinforcers of positive change including feeling better. Help access family/social/peer support.
in maintenance phase related - ISSUE(S). Help identify & try supportive bx & activities - maintain goals. Maintain supportive contact & highlight progress in maintaining improved functioning - what was role of ISSUE(S) (i.e. BMI, diabetes, / substance use & health)? Set new short & long term goals for health & ISSUE(S).
in recurrence phase related - ISSUE(S). Frame recurrence learning opportunity - what was impact on health? Explore possible psychological, bx, & social antecedents. Help - develop alternative coping strategies for strong emotions. Encourage - stay in process & maintain support. [/textarea] [textarea] Long Term Goals:
Target Date:
Short Term Goals:
Interventions:
Individual Therapy Sessions:
Primary Therapist:
Group Therapy:
Psychiatric Appointments:
Family Therapy:
Family/Social Support Involvement:
satisfied w/ these supports / would like - improve / makes changes - this area?
Drug Screen Results:
Need for IOP tx:
Progress - Date:
Collateral Contact:
Clien'ts Self -Stated Goals:
Self-Reported Progress:
Additional Background Information
Goals of Care [/textarea] [textarea] My GOALS OF CARE LIFE-SUSTAINING LIMITED tx COMFORT MEASURES in WHAT LOCATION. [/textarea]
reports marital status [textarea] SINGLE MARRIED DIVORCED WIDOWED COHABITING. SPOUSE PARTNER SUPPORT PERSON NAME & DOES NOT live w/ . reports NO children.
Potential opportunity for Medicaid: self-pay & has NO children on Medicaid. [/textarea] [textarea] reports following spiritual belief/support:
reports following cultural practices/support:
Disability
DENIES REPORTS receiving disability benefits for
Military Service
DENIES REPORTS veteran status. NOT Gold Star Parent. DENIES REPORTS active w/ VA clinic. States DD214 NOT available. states this team MAY NOT contact VA clinic - inquire about assistc. / extra resources. [/textarea]
Case Management Services [textarea] DENIES REPORTS active case management engagement. AGENCY case manager NAME (Phone#) working w/ for REASON. AGENCY case manager NAME (Phone #) working w/ for REASON.
Self-Management Needs
reports following self management needs: LIST NONE. [/textarea]
Education [textarea] requests following education: NONE
Specialists
DENIES REPORTS engagement w/ specialists & // other providers. DETAIL NAME/REASON HERE.
OBJECTIVE
Observations related - completion of assessments.
ASSESSMENT
goal of LIFE SUSTAINING LIMITED tx MEASURES in WHAT LOCATION NOT consistent w/ tx plan. [/textarea]
meds [textarea] med Reconciliation was completed.
meds (prescribed, herbal, OTC) reported by /patients pharmacy NOT consistent w/ those noted by PCP. following meds inconsistent w/ PCP med list:
High-Risk medsnoted - be taking following class of high-risk meds: INSERT / not noted - be taking high-risk meds.
Poly-pharmacy (> 5 meds)
NOT on more than 5 meds. [/textarea]
DISEASE [textarea] NOT diabetic. last reported eye exam was performed by NAME OF DR on DATE.
HAS NOT been 366 days since last reported eye exam.
Low back pain
DOES NOT HAVE low back pain & HAS NOT had imaging studies.
Complex dx
DOES NOT have complex dx of
CHF
Cerebrovascular Disease/CVA
Advanced COPD
DM
End Stage Dementia
End Stage Renal Disease
CA
HIV – AIDS
Frailty / Failure - Thrive
Palliative Care Needs
has life-limiting condition likely - benefit from sx management (DETAIL)
Advanced Health Care Directive (AHCD)
DOES NOT HAVE AHCD & all providers/specialists/local hospital DO NOT have copy of document. There NO family / support dynamics relevant - implementation/completion of AHCD. [/textarea]
Health Literacy
[textarea] primary language NOT English. (Detail) DOES NOT have good understanding of current health state. (Describe)
following self-management needs noted: No self-management needs noted this time. [/textarea]
Education Needs [textarea] following educations needs noted: No education needs noted this time. [/textarea]
PSYCHOLOGICAL
SOCIOECONOMIC [textarea] DOES NOT HAVE adequate support (Describe).
Hospitalizations / Unplanned Access
In past year, has been hospitalized INSERT times. (DETAIL) [/textarea]
HEALTH bx
Tobacco use [textarea] has never used nicotine.
has hx of using (TYPE OF NICOTINE)
How many (PACKS, CANS, BAGS ETC).
For how many yrs? [/textarea]
BMI [textarea] PCP visit on DATE, VERBALIZED CONCERN OF incr RISK DUE - .
FUNCTIONAL STATUS
Fall Risk [/textarea]
ADLs/iADLs [textarea] independent w/ all ADLs.
independent w/ all iADLs.
not independent w/ following ADLs:
not independent w/ following iADLs: [/textarea]
Stage of Change related - health & wellness risks [textarea] in pre-contemplation phase re: : ISSUE(S)
in contemplation phase re: : ISSUE(S)
in determination phase re: : ISSUE(S)
in action phase re: : ISSUE(S)
in maintenance phase re: : ISSUE(S)
in recurrence phase re: : ISSUE(S) [/textarea]
Progress Notes
Chronic sx & dx Justification: [textarea] Indicate chronic/ongoing sx struggles w/
& justification for dx impression
(I.E. Sleep, Appetite, Suicide/Homicidal Ideation, Mood Swings, Depression, Anxiety, Panic Attacks, OCD, Hallucinations, Delusions, Anger, Attention/Concentration)
Indicate what these sx LOOK LIKE,
(I.E. if Paranoia identified, explain what this looks like, how often, triggers - , how effects functioning, etc.)
Functional areas - be addressed[/textarea] [textarea] Psychiatric
Medical
Social/Family
Legal
Educational
Financial
Housing
Specific social, bx, / medical services need assistc. in linking.
Include narrative thinking medical necessity
(Housing, medical care, coordinating transportation, legal matters, childcare, employment, bx healthcare, educational/continuing education, public assistc.):
If determination has been made we unable - serve this , make appropriate referrals - other agencies - meet identified needs: [/textarea]
*OTHER RECOMMENDED ACTIONS* [textarea] . capacity - engage in services:
(age specific, demonstrated cognitive capacity - benefit from services):
What skills & knowledge needed for - achieve rehabilitation goals:
Care coordination w/ . & // guardian / other representative & tx agreement was confirmed.
guardian agreed - contact provider / office if problems / concerns.
Discussed dx & tx options including meds (indication, potential side effects, & risks vs benefits) [/textarea] [textarea] sample text [/textarea]
tx goals [textarea] reduce
increase
increase ability
effectively manage sx of
independently [/textarea] decrease [textarea] sx Mgmt
decrease sx of
eliminate
initiate[/textarea]
Common Goals [textarea] eliminate intrusive thoughts of traumatic event from daily to zero per week
daily
to
3-5x/wk
at least
over next
6 months
method [/textarea] [textarea] initiating # social interactions per week as observed by
utilize peer support
independently identify

tx goals [textarea] reduce
increase
improve
effectively manage
demonstrate
increase ability
effectively manage sx of
effectively manage sx related
identify barriers
implement
independently [/textarea] decrease [textarea] sx Mgmt
decrease sx of
eliminate
initiate[/textarea]
Common Goals [textarea] eliminate intrusive thoughts of traumatic event from daily to zero per week
from
daily
to
3-5x/wk
at least
over next
6 months
method [/textarea] [textarea] initiating # social interactions per week as observed by
utilize peer support
independently identify [/textarea]
Dx List
Expected Length of tx:
--
tx PLAN

Tx Plan:
Will
Control
Receive
Discuss
incr. / ImproveDecr.
Evidenced By
Objectives Of Tx:
Reduce Anxiety - Relaxation training
-Psychoeducation-
elim Substance Abuse

elim Self Harm
Mi [/textarea]
Process Grief & Loss-Appointments w/ Grief
Reduce Traumatic Responses -
Evaluate Marital Status
Improve Sleep Quality-Sleep Hygiene Habits IncludeRelaxation
Improve Parenting Skills-Love & Logic training.
By
Status Of Problem/Focus Of Tx:


GOALS & OBJECTIVES
Goals:
sx MANAGEMENT
OBJECTIVES:

Presenting Problem
Presenting Target sx (Include Duration)

DSM 5
ASSESSMENT OF NEEDS

Environmental Needs
Proactive identification, outreach, & assessment - intervene early possible along wellness/ disease continuum.
Beacon Emotional Problems List:
If checked box should talk about your feelings w/ your healthcare provider soon possible There help available
Physical Activity Checklist
LONG-TERM GOALS:
SHORT-TERM OBJECTIVES
Items wnl/Completed/Improved.
reports marital status
Case Management Services
Education
meds
DISEASE
Health Literacy

Education Needs
PSYCHOLOGICAL
SOCIOECONOMIC
HEALTH bx
Tobacco use
BMI
ADLs/iADLs
Stage of Change related - health & wellness risks
Progress Notes
Chronic sx & dx Justification:
*OTHER RECOMMENDED ACTIONS*
tx goalsdecrease
Common Goalsdecrease
Common Goals

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