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Psychotherapy Note

posted 2024-02-01, updated 2024-02-01

Tags: checkbox, medicalnecessity, psychotherapy

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Met with patient. Patient reports doing [checkbox name="concerns" value="okay|better than last meeting|worse compared to last meeting|not so good"]
Patient Quotes [text name="variable_1" default="sample text"]

Patient reports experiencing symptoms of [checkbox name="variable1" value="anxiety|depressed mood|sadness|loss of interest in pleasurable activities|tearful or crying spells|fatigue/low energy|difficulty sleeping|trouble falling asleep|appetite changes|difficulty concentrating|low motivation|poor academic/work performance|isolation from others|loneliness|low self-esteem|suicidal ideation|anxiety of social situations|concerns of negative evaluation by others|fear of embarrassing self|panic/abrupt surge of intense fear/intense discomfort|worry about having future panic symptoms/attacks|muscle tension|difficulty controlling worry/excessive worrying|worry about job responsibilities|worry about health|worry about finances|panic attacks|fear|hopelessness|impulsivity|hypervigilance|grief|worry about future of relationship|low self-confidence|interpersonal conflicts|irritability|emotional instability|psychosis|other"][text name="variable5" default=""] 


Patient discusses [checkbox name="variable4" value="symptom management|management of depression symptoms|management of anxiety symptoms|self-esteem|ADHD|friendships|childhood/family of origin|emotion dysregulation|anger issues|distress intolerance|an adjustment to a stressor(s)|grief/loss|relationship distress|relationship dissatisfaction|relationship argument or regrettable incident with partner|relationship intimacy concerns|interpersonal ineffectiveness/conflict|boundary setting|a conflict with peers|a conflict with family|a conflict with coworker(s)|self-care/hygiene issues|sleeping issues|physical activity/exercise|substance use concerns|alcohol use concerns|cannabis use concerns|nicotine use concerns|trauma|stressor(s)/coping mechanism(s)|familial relationship distress|employment issues|financial issues|legal issues|housing issues|parenting stress|medical/health concerns|medication concerns|religious/spiritual concerns|other"][text name="variable6" default=""].


Patient displays [checkbox name="variable16" value="awareness of emotions|motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions/feelings|willingness to be vulnerable and ask for help from others at critical times|awareness and honesty around negative coping techniques|the ability to tolerate painful or uncomfortable feelings|openness to trying new, positive behaviors|seeking positive relationships|having compassion for self"]


Progress
[checkbox name="variable2" value="symptoms continue to wax and wane.|Patient continues to remain sober.|Recent relapse.|Difficulty implementing tools/skills    discussed"][text name="variable2" default=" "]

[checkbox name="variable3" value="Patient denies current prescription of medication(s).|Patient reports no changes to prescribed medication(s).|Patient reports changes to prescribed medication(s).|Patient notes"][text name="variable3" default=" "]

Medical Necessity for Extended session CPT 90837 [checkbox name=[checkbox name="extended_reasons" value="clinical symptoms cause functional impairment in ability to complete activities of daily living, occupational functioning, and/or social functioning that is not characteristic with the person is not symptomatic|time needed to address and contain intense issues|client presents with multiple life stressors|symptoms are impacting multiple domains of life (Relationships, work, school community)|client trauma history exploration|significant trauma history necessitates additional time for disclosure and containment|grounding needed for symptoms that emerged during session|addressing complicated issues related to diagnosis and clinical presentation|addressing new or emergent symptoms|client reports subjective level of distress|client reports subjective level of acute issues|assessment and stabilization|client crisis|client presenting with acute issues|client at risk of inpatient treatment or ED admissions due to possibility of decompensation without the current level of care|current level of treatment is necessary as the client continues to meet diagnositc criteria and identifies symptoms that impair functioning. Without continued care at this level the client may deteriorate, be unable to maintain improvements or continue to make gains||client requested longer session due to decreased frequency of sessions|utilizing exposure therapy for ptsd, panic disorder, OCD or specific phobia|parental involvement for psychoeducation or emotional management skills|limited health support network|client is unable to share content with others in support system due to nature of topic|IFS protocol being utilized|bi-weekly sessions|monthly sessions to maintain acquired skills|"] 




Patient will[checkbox name="cb12" value=    "implement techniques discussed in session.|identify triggers that impact mental health symptoms|contact therapist to schedule next session."]
Additional plan:[text name="variable_2" default="sample text"]

Therapist will [checkbox name="cb14" value="continue to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with patient as scheduled and determine need for termination|begin termination process with patient|Therapist will contact patient to schedule next session."] Patient agreed to this plan.

Met with patient. Patient reports doing okay better than last meeting worse compared to last meeting not so good
Patient Quotes

Patient reports experiencing symptoms of anxiety depressed mood sadness loss of interest in pleasurable activities tearful or crying spells fatigue/low energy difficulty sleeping trouble falling asleep appetite changes difficulty concentrating low motivation poor academic/work performance isolation from others loneliness low self-esteem suicidal ideation anxiety of social situations concerns of negative evaluation by others fear of embarrassing self panic/abrupt surge of intense fear/intense discomfort worry about having future panic symptoms/attacks muscle tension difficulty controlling worry/excessive worrying worry about job responsibilities worry about health worry about finances panic attacks fear hopelessness impulsivity hypervigilance grief worry about future of relationship low self-confidence interpersonal conflicts irritability emotional instability psychosis other

Patient discusses symptom management management of depression symptoms management of anxiety symptoms self-esteem ADHD friendships childhood/family of origin emotion dysregulation anger issues distress intolerance an adjustment to a stressor(s) grief/loss relationship distress relationship dissatisfaction relationship argument or regrettable incident with partner relationship intimacy concerns interpersonal ineffectiveness/conflict boundary setting a conflict with peers a conflict with family a conflict with coworker(s) self-care/hygiene issues sleeping issues physical activity/exercise substance use concerns alcohol use concerns cannabis use concerns nicotine use concerns trauma stressor(s)/coping mechanism(s) familial relationship distress employment issues financial issues legal issues housing issues parenting stress medical/health concerns medication concerns religious/spiritual concerns other.

Patient displays awareness of emotions motivation to progress in treatment utilization of positive coping techniques ability to express emotions/feelings willingness to be vulnerable and ask for help from others at critical times awareness and honesty around negative coping techniques the ability to tolerate painful or uncomfortable feelings openness to trying new, positive behaviors seeking positive relationships having compassion for self

Progress
symptoms continue to wax and wane. Patient continues to remain sober. Recent relapse. Difficulty implementing tools/skills discussed

Patient denies current prescription of medication(s). Patient reports no changes to prescribed medication(s). Patient reports changes to prescribed medication(s). Patient notes

Medical Necessity for Extended session CPT 90837 clinical symptoms cause functional impairment in ability to complete activities of daily living, occupational functioning, and/or social functioning that is not characteristic with the person is not symptomatic time needed to address and contain intense issues client presents with multiple life stressors symptoms are impacting multiple domains of life (Relationships, work, school community) client trauma history exploration significant trauma history necessitates additional time for disclosure and containment grounding needed for symptoms that emerged during session addressing complicated issues related to diagnosis and clinical presentation addressing new or emergent symptoms client reports subjective level of distress client reports subjective level of acute issues assessment and stabilization client crisis client presenting with acute issues client at risk of inpatient treatment or ED admissions due to possibility of decompensation without the current level of care current level of treatment is necessary as the client continues to meet diagnositc criteria and identifies symptoms that impair functioning. Without continued care at this level the client may deteriorate, be unable to maintain improvements or continue to make gains client requested longer session due to decreased frequency of sessions utilizing exposure therapy for ptsd, panic disorder, OCD or specific phobia parental involvement for psychoeducation or emotional management skills limited health support network client is unable to share content with others in support system due to nature of topic IFS protocol being utilized bi-weekly sessions monthly sessions to maintain acquired skills

Patient will implement techniques discussed in session. identify triggers that impact mental health symptoms contact therapist to schedule next session.
Additional plan:

Therapist will continue to assess mood/functioning, and implementation of treatment plan goal(s) follow up with patient as scheduled and determine need for termination begin termination process with patient Therapist will contact patient to schedule next session. Patient agreed to this plan.