DAP progress note RF

Client Name: {FIRSTNAME} {LASTNAME} ({BIRTHDAY})
Appointment: {APPOINTMENTDATE} from {APPOINTMENTSTARTTIME} to {APPOINTMENTENDTIME}
Exact start and stop times:
CPT Code: {CPTCODE}
Session type: 90837-95 psychotherapy, 60 minutes, telehealth modifier  
POS Code: {POSCODE}
Location: HIPAA compliant Google Meet/video/telehealth
Diagnosis:
Client location at time of session: Home address
Attendees: Client and therapist
Telehealth consent obtained: Yes
Important information for use of telehealth:  Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

DATA
Client is a {AGE} yo self-identified [select name="gender" value="female|male|non-binary"] who presents today on HIPAA compliant Google Meet platform for follow up on symptoms of [checkbox name="variable_1" value="depression|anxiety|panic|ADHD|PTSD/trauma|grief|adjustment disorder|relationship/marriage concerns|Bipolar disorder|insomnia"].
[textarea name="presentation" default="Client is oriented x3, mental status and functioning appear to be WNL. Client's observed affect is (full, flat, blunted, labile, tearful, appropriate, inappropriate, restricted) and client reported their mood to be (euthymic, depressed, anxious, irritable, angry, sad, elevated). Client's observed behavior and appearance both appropriate."]

[checkbox name="Depression" memo="Depression" value=""][checkbox name="Anxiety" memo="Anxiety" value=""][checkbox name="Panic" memo="Panic" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="PTSD" memo="PTSD" value=""][checkbox name="Bipolar" memo="Bipolar Disorder" value=""][checkbox name="Insomnia" memo="Insomnia" value=""][checkbox name="AdjustmentDisorder" memo="Adjustment Disorder" value=""][conditional field="Depression" condition="(Depression).is('')"] Depression is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy/fatigue|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"][textarea memo="Additional information" rows="1"][/conditional][conditional field="Anxiety" condition="(Anxiety).is('')"] Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy/fatigue|muscle tension|headaches|feeling overwhelmed|restlessness|loss of appetite"][textarea memo="Additional information" rows="1"][/conditional][conditional field="Panic" condition="(Panic).is('')"] Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"].
Client is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"][textarea memo="Additional information" rows="1"][/conditional][conditional field="ADHD" condition="(ADHD).is('')"] ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"][textarea memo="Additional information" rows="1"][/conditional][conditional field="PTSD" condition="(PTSD).is('')"] PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"][textarea memo="Additional information" rows="1"][/conditional][conditional field="Bipolar" condition="(Bipolar).is('')"] Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"][textarea memo="Additional information" rows="1"][/conditional][conditional field="Insomnia" condition="(Insomnia).is('')"]
Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"][textarea memo="Additional information" rows="1"][/conditional][conditional field="AdjustmentDisorder" condition="(AdjustmentDisorder).is('')"]
Adjustment disorder symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client is reporting [checkbox value="marked distress that is disproportionate to the severity/intensity of stressor|significant impairment in social, occupational, and other areas of functioning|depressed/low mood|anhedonia|tearfulness|feelings of hopelessness|nervousness|worry|difficulty concentrating|feeling overwhelmed"][textarea memo="Additional information" rows="1"][/conditional]

Overall goals of session: [checkbox name="Goals" value="symptom reduction|skill acquisition|improve functioning|improve health|maintain positive gains|reduce ineffective behaviors|safety planning|treatment review|termination/discharge|xxxxxx"]. Specific treatment goals addressed this session include [checkbox name="goals" value="reducing overall level, frequency, and intensity of anxiety|improving/developing coping skills| reducing symptoms of depression| reducing symptoms of PTSD| improving overall mood| coping with routine life stressors| improving executive functioning skills| improving quality of interpersonal relationships| resolving issues related to traumatic event| processing grief/loss| learning effective communication strategies"].

[textarea name="focus" default="To address client's symptoms and achieve therapeutic goals, focus of session included processing/reviewing recent events in the client’s life, current expression and management of symptoms, exploration of life stressors, friendships/interpersonal relationships/conflicts, communication issues/concerns, substance use concerns, goal setting, treatment plan review/formation, family of origin history/background, trauma, past distressing memory, self-care activities, self-esteem, sleep/nutrition habits, processing/exploring grief, school problems, work problems, parenting issues/stress, rapport building."]

Therapist utilized open ended questions to elicit more information regarding... and aided client in processing thoughts, emotions and perceptions related to issues at hand. Therapist engaged client in Socratic questioning and utilized reflection to support client in expressing and exploring their emotions. Therapist also [checkbox name="interventionsprovided" value="reinforced use of healthy coping strategies/positive self talk/assertive communication|explored the client's stressors and frustrations| worked with client to develop more effective solutions/coping| collaborated with client to problem solve presenting issues/barriers to accomplishing goals| provided psychoeducation on presenting concerns|explored connections between actions, emotions, and cognitions (thoughts or beliefs)| guided client in examination of unresolved conflicts and significant past events to gain insight"]. Additionally, therapist assisted client with [checkbox name="interventions2" value= "self advocacy/communicating needs|identifying pros/cons to change|identifying/labeling emotions| identifying negative thinking patterns|identifying source of distorted thoughts| identifying hobbies/values| connecting past experiences to present behaviors|identifying new insights into problems and symptoms|identifying patterns of avoidance| identifying/exploring triggers|identifying strengths and support system|identifying and setting goals|identifying how current thoughts/beliefs influence their mood and behaviors| identifying situations that are anxiety provoking|exploring impact of trauma on their life|exploring family of origin|exploring effects of childhood experiences|exploring history of...|exploring issues around trust|exploring issues of unresolved grief/loss|exploring patterns of conflict within the family/relationship|exploring family dynamics|practicing cognitive challenging/reframing| practicing relaxation techniques/mindfulness practices/grounding techniques"].
Client is open to interventions, motivated to progress in treatment, and engaged in discussion with therapist throughout. 

ASSESSMENT
No SI/HI, A/V hallucinations or other additional risk factors identified at this time; no contrary clinical indications present, therapist will continue to monitor. Client [select name="carecoord" value="denied|endorsed"] need for care coordination at this time. Client [select name="meds" value="denied|endorsed"] medication changes/dosages.

[textarea name="impairment" default="Client endorsed functional impairment in several areas, including overall wellbeing, sense of self/meaning from life, ability to perform daily necessary tasks for life, satisfaction or productivity at work/school, ability to engage and/or derive satisfaction from social connections, satisfaction and stability in family life and connections."]

Client is currently displaying [select value="symptoms of |well managed |moderately managed |poorly managed "][checkbox value="depression|anxiety|sleep disturbance|recent substance use|substance use disorder|mild|moderate|severe|in early remission|in sustained remission|PTSD|ADHD|impulsivity|mood lability"][textarea default="" rows="2"]. 
[textarea name="symptomsreported" default="Client continues to report symptoms consistent with current diagnosis including (depressed mood, anhedonia, difficulty concentrating, feeling tense/on edge, restlessness, excessive worrying/difficulty controlling worry, interpersonal conflicts, crying episodes, negative cognitions, hypervigilance/easily startled, irritability, sleep disturbance, appetite changes, somatic symptoms, panic attacks, fear of embarrassing self, anxiety of social situations, avoidance, inattention, task avoidance, intrusive thoughts, feelings of worthlessness/inappropriate guilt, hopelessness, and feeling tired/fatigue/low energy)"].
The client's reported symptoms are consistent with: [checkbox name="diagnosis" value="Anxiety disorders|Trauma and stressor related disorders|Depressive disorders|Mood disorders|Adjustment disorder|Neurodevelopmental Disorders (ADHD/ASD)|Other"] [text name="other" default=""]

Client's progress is best described as [select name="response" value="responding well to interventions/making good progress.|making slow progress.|making intermittent progress.|maintaining progress.|regressing/worsening."] Progress is indicated by therapist's observation as well as client's report of [checkbox name="strengths" value="regular utilization of effective coping strategies|improved insight into their responses and natural/conditioned ways of thinking| increased capability to appropriately identify and express emotions| improved capacity for emotion regulation| improvement in tolerance for frustration| increased capability to tolerate painful feelings| increased capacity to show compassion for themself| improvement in ability to manage and respond appropriately to symptoms| positive adjustments to their mindset and former distortions"]. However, client continues to experience challenges with [checkbox name="problems" value="recognizing/labeling emotions| effectively expressing thoughts and feelings| managing and responding appropriately to symptoms| regularly utilizing learned adaptive coping skills| utilizing effective communication skills| executive functioning skills| emotional/affect regulation| sleep|poor insight|social functioning/relationships| practicing personal hygiene/self care"], which continue to negatively and significantly impact the client's quality of life. 

Medical necessity/factors influencing length and/or frequency of sessions include [checkbox name="mednec" value="client presents with multiple life stressors|client requested longer session due to decreased frequency of sessions| bi-weekly sessions| monthly sessions to maintain acquired skills| symptoms are impacting multiple domains of life (relationships, work, school community)| assessment and stabilization| significant trauma history which necessitates additional time for disclosure and containment| EMDR protocol being utilized| therapeutic intervention utilized in session| time needed to address and contain intense issues|parental involvement for psychoeducation or emotional management skills"]

Client requires ongoing treatment of the diagnosed condition to [select name="necessity" value="prevent decompensation and maintain progress.|prevent higher level of care.|address symptoms and achieve symptomatic relief.|improve functioning in one or more areas."]

PLAN
The ongoing treatment plan includes [textarea name="txplan" default="continuation of the treatment as indicated, therapeutic interventions aimed at helping with target behaviors and difficulties, therapeutic interventions aimed at better understanding the impact of the client's traumatic history on present day relationships and experiences, continued implementation of cognitive-behavioral interventions to address the target difficulties, continued implementation of EMDR to address the client’s traumatic memories."]

Changes in diagnosis or treatment plan: [select name="plan" value="None indicated at this time.|Increase session frequency due to increased symptoms or safety concerns.|Decrease session frequency.|Moving toward discharge, decrease session frequency and monitor for stability and maintenence of gains.|Discharge and close file.|Higher level of care needed, referred to xxxxxx for assessment and indicated treatment before returning to outpatient treatment."]

Planned actions for future sessions: Therapist will continue to utilize [checkbox name="ebt" value= "CBT|EMDR|CPT|PE|Mindfulness-based|Behavioral activation|TF-CBT|Solution-Focused Therapy|DBT skills|Other"]

Date of next session: [date name="date1"]

Homework: Client agreed to [checkbox name="homework" value="practice strategies taught in session|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|tracking mood, and triggers for mood fluctuations|following 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"][text name="homework" default=""]

Client's overall prognosis is [select name="prognosis" value="good|fair|guarded|poor"]
Client Name: {FIRSTNAME} {LASTNAME} ({BIRTHDAY})
Appointment: {APPOINTMENTDATE} from {APPOINTMENTSTARTTIME} to {APPOINTMENTENDTIME}
Exact start and stop times:
CPT Code: {CPTCODE}
Session type: 90837-95 psychotherapy, 60 minutes, telehealth modifier
POS Code: {POSCODE}
Location: HIPAA compliant Google Meet/video/telehealth
Diagnosis:
Client location at time of session: Home address
Attendees: Client and therapist
Telehealth consent obtained: Yes
Important information for use of telehealth: Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

DATA
Client is a {AGE} yo self-identified who presents today on HIPAA compliant Google Meet platform for follow up on symptoms of .


Depression Anxiety Panic ADHD PTSD Bipolar Disorder Insomnia Adjustment Disorder

Overall goals of session: . Specific treatment goals addressed this session include .



Therapist utilized open ended questions to elicit more information regarding... and aided client in processing thoughts, emotions and perceptions related to issues at hand. Therapist engaged client in Socratic questioning and utilized reflection to support client in expressing and exploring their emotions. Therapist also . Additionally, therapist assisted client with .
Client is open to interventions, motivated to progress in treatment, and engaged in discussion with therapist throughout.

ASSESSMENT
No SI/HI, A/V hallucinations or other additional risk factors identified at this time; no contrary clinical indications present, therapist will continue to monitor. Client need for care coordination at this time. Client medication changes/dosages.



Client is currently displaying
.
.
The client's reported symptoms are consistent with:

Client's progress is best described as Progress is indicated by therapist's observation as well as client's report of . However, client continues to experience challenges with , which continue to negatively and significantly impact the client's quality of life.

Medical necessity/factors influencing length and/or frequency of sessions include

Client requires ongoing treatment of the diagnosed condition to

PLAN
The ongoing treatment plan includes


Changes in diagnosis or treatment plan:

Planned actions for future sessions: Therapist will continue to utilize

Date of next session:

Homework: Client agreed to

Client's overall prognosis is

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.74, 69 form elements, 360 boilerplate words, 2 text boxes, 14 text areas, 1 dates, 28 checkboxes, 16 drop downs, 8 conditionals, 298 total clicks
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