Progress Note
[textarea name="variable_1" default="Content Or Topics Discussed"] [textarea name="variable_1" default=" Discussed Following Topics:"] [checklist name="variable_1" value="option A|option B|option C"] Counseling Session Last Counseling Session: Last Medical Appointment: Last Drug Screen: & Results Reported As [select name="variable_1" value="Normal|Abnormal"]. Came To Office [checklist name="variable_1" value="To Engage For Monthly Counseling|At Request To See Counselor"] Invited To Initiate Session By Asking To Share Current Status. [textarea name="variable_1" default="Reported"] [textarea name="variable_1" default="progress towards goals"] [textarea name="variable_1" default="symptom progression"] sleep hygiene discussed including [checklist name="variable_1" value="establishing regular relaxing bedtime routine|exposure to sunlight during day, as well as darkness at night|limiting screen time before going to bed|exercise during day|impact of substance use on sleep"] discussed ways to better manage finances: [checkbox name="variable_1" value="have spending plan or budget|track monthly spending|prioritizing spending on groceries, personal care items"] education provided re: health benefits of socialization & ways to improve socialization including [checkbox name="variable_1" value="forcing yourself to go out even when don't want|to practice conversation starters|option B|option C"] nutrition discussed including [checkbox name="variable_1" value="role of nutrition in mental well-being|heart healthy diet|importance of including variety of fruits & vegetables|limiting or eliminating processed food & sweetened beverages"] [checkbox name="variable_1" value="Demonstrated Active Listening Skills"] When Finished Reporting Self-Identified Status [checklist name="variable_1" value="Used Reflection, & Clarified Priorities & Readiness|Used Collaborative Approach To Agenda Map| Identifying [text name="variable_1" default=""] As Being An Area to Be Primary Focus For Session. [checklist name="variable_1" value="option A|option B|option C"]Used Open-Ended Questions To Assist In Exploring Problem Further, | Assessed Understanding & Previous Barriers. |Provided Affirmations & Built Confidence Through Ask-Tell-Ask, | Praise Given To Support [textarea name="variable_1" default="Praise: Specify At Least 1 Positive Event, Attitude Or Strength Of Identified"] Asked To Consider Incremental Changes To Address Reported Barriers. Able To Identify [Text Name="Variable_7" Default=""] As Possibility. Used Scaling Questions To Assess Readiness & Commitment [checkbox name="variable_1" value="Worked Collaboratively w/ To Develop Plan That Includes Adequate Structure, Accountability, Benchmarks & Rewards|Developed Homework For Next Session."] Appears To Be In [select name="variable_1" value="Pre-Contemplative|Preparatory|Action|Maintenance"] [textarea name="variable_1" default="Stage Of Change As Evidenced By"] Progress In Achieving Treatment Goals Is Best Assessed As [radio name="variable_1" value="Minimal|Inconsistent|Progressing|Improving|Stable"] As Evidenced By [radio name="variable_1" value="Self-Reports|Drug Screen Results|Behavior & Engagement"] Next Session Scheduled For Reports Commitment To [text name="variable_1" default=""] [textarea name="variable_1" default="Prior To Next Session. "] [checkbox name="variable_1" value="Will Remain Available To Offer Ongoing Resources If Support Needed Between Session."] [textarea name="variable_1" default="Resources Provided:"] [checklist name="variable_1" value="Mi Worksheet- Agenda Mapping.|Mi Worksheet- Exploring Pros & Cons|Mi Worksheet- Change Plan|List Of Community Resources For |Referral To |Phone Numbers For "] [textarea name="variable_1" default="Specific Resources, Resources Not Listed, Or Indicate None"] [checklist name="Interventions" Asked open ended questions|utilized reflective listening|conducted mental status exam|provided psychoeducation around|modeled technique|used exercise|Used motivational interviewing to increase motivation around"] [textarea name="variable_1" default=""] [checklist name="variable_1" behavior modification|cbt |choice making |client centered|communication skills |coping skills |crisis |crisis intervention|dbt|family/couples |flat |grief work |hallucinations |limit setting |mindfulness |motivational interviewing |parenting skills |positive reinforcement |problem solving |psychoeducation |rapport building |reality testing |redirection |reframing |relaxation training |role playing |stress reduction |structural family therapy |support linking |supportive interaction |telephone call|solution focused |support linking|supportive therapy|coping skills|validation| centered "] [checklist name="to" In Order to... |Reduce sx of |help articulate feelings about |encourage to share thoughts around |help make plan around"] [comment memo=" ICD-10 codes are here http://apps.who.int/classifications/icd10/browse/2010/en#/V"] Subjective: When asked to rate how things have been over last week, reported that [select name="Q1" things have been unremarkable.|there have been some difficulties.|life has been pretty good.|"][conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"] When asked to elaborate, reported concerns w/: [conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"] lastweek" primary support group| social environment|education|work|housing|finances|access to health care services|legal justice system|psycho-social functioning & environment"].[/conditional] [textarea cols=80 rows=5 default="additional comments"] sleep [select good|fair|poor|terrible"]; appetite [select good|fair|poor|terrible"]; concentration [select good|fair|poor|terrible"]; & energy levels were [select good|fair|poor|terrible"]. Attitude towards treatment -- [select unable to rate| highly beneficial.| occasionally helpful.| not helpful."] Formulation -- [textarea cols=80 rows=5 default=" presented today w/ this problem, because of this reason."] Treatment -- [textarea cols=80 rows=5 default="because of above formulation I treated w/ CBT"] Prognosis -- At time of writing, prognosis is [select good|fair|poor|uncertain"]. Plan: Treatment goals -- In terms of future treatment, [textarea cols="50" rows="5" default="based on todays treatment, I will therefore continue w/ CBT, or change to another modality, & book apt w/ doctor"]. Next appointment -- next appointment is scheduled for [textarea cols=10 rows=1 default="day"], [textarea cols=10 rows=1 default="date"] at [textarea cols=10 rows=1 default="time"].
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.58, 48 form elements, 198 boilerplate words, 1 text boxes, 18 text areas, 6 checkboxes, 9 check lists, 2 radio buttons, 9 drop downs, 1 comments, 2 conditionals, 68 total clicks
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