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"].