Progress Note SOAP

SUBJECTIVE

Focus of Session/Session Content:
Met with patient. Patient reports doing:
[checkbox name="concerns" value="Okay|better than last week|not well|worse compared to last week"]

Patient reports symptoms of:
[checkbox name="symptoms" value="Depressed mood|Sadness|Anhedonia|Tearful or crying spells|Fatigue/low energy|Negative cognitions|Restlessness|Difficulty sleeping|Trouble falling asleep|Appetite changes|Low motivation|Difficulty with organization|Hyperactivity|Inattention|Task avoidance|Difficulty with task initiation|Difficulty handling transitions|Difficulty persisting on challenging or tedious tasks|Concrete/literal thinking|Difficulty handling ambiguity/uncertainty|Sensory difficulties|Poor academic/work performance|Isolation from others|Loneliness|Low self-esteem|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|Difficulty concentrating|Muscle tension|Feeling on edge|Difficulty controlling worry/excessive worrying|Worry about work/school|Worry about health|Worry about finances|Panic attacks|Fear|Hopelessness|Feelings of worthlessness/inappropriate guilt|Intrusive thoughts|Flashbacks|Dissociation/Depersonalization/Derealization|Avoidance of thoughts/memories of traumatic event|Impulsivity|Obsessions/compulsions|Phobias|Self-harm|Substance abuse|Nightmares|Hypervigilance/Easily startled|Grief|Worry about future of relationship|Low self-confidence|Interpersonal conflicts|Irritability|Emotional instability|Other"][text name ="other" default""]

Focus/themes of session for today was:
[checkbox name="topics" value="----MOOD MANAGEMENT----|Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotion dysregulation|Distress intolerance|Anger issues|Negative cognitions|----ADHD----|ADHD symptoms|ADHD treatment/medications|Self-esteem|Management of executive dysfunction|
----GENDER/SEXUALITY----|Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others|----OTHER TOPICS----|Homework/assignment follow up|Goals/treatment plan review|Client history/background|----ATTACHMENT ISSUES---|Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear of developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult attachment avoidance|Fear of intimacy|Excessive need for self-reliance|Distrust of others|
----RELATIONSHIP DISTRESS----|Relationship dissatisfaction|Conflict/argument with partner|Intimacy concerns|Infidelity/affair concerns|Child custody conflict|Codependency issues|Divorce issues|Trust concerns|Communication problems with partner|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma|----ADJUSTMENT DISORDER----|Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event|----GRIEF/LOSS----|Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss|----INTERPERSONAL PROBLEMS----|Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict with extended family|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|----BEHAVIORAL HEALTH ISSUES----|Self-Care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|------SUBSTANCE USE ISSUES----|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention|----TRAUMA----|Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|----STRESSORS----|Life stressors|Stressor/coping mechanism(s)|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Parenting stress|----MEDICAL & HEALTH ISSUES----|Medical/health concerns|Medication concerns|New diagnosis|Physical pain|----RELIGIOUS ISSUES----|Religious/spiritual concerns|Other"][text name="other" default=""]

Changes in medication: [text name="medication" default=""]

Safety/Risk Factors:
[checkbox name="safety" value="SI/HI denied|Endorsed suicidal ideation|Endorsed passive SI|Endorsed active SI with a method but without plan or intent to Act|Endorsed recent suicide attempt|Endorsed Nonsuicidal Self-Injury|Denied homicidal ideation|No additional risk factors present"]

OBJECTIVE

Mental Status Exam:
Orientation: [checkbox name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"] Time: [checkbox name="time" value= "On time|Late" Appearance: [checkbox name="appearance" value="Clean/Neat|Casual|Desheveled"] Affect: [checkbox name="MSE2" value="Full range|Flat|Blunted|Labile|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inappropriate to mood and thoughts|Restricted in range, mood congruent"] Mood: [checkbox name="mood" value="Euthymic|Depressed|Anxious|Irritable|Elevated|Other"][text name="other2" default=""] 
Speech: [checkbox name="MSE4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|Soft"] Behavior: [checkbox name="MSE_5" value="WNL|Appropriate|Inappropriate"] Thought process: [checkbox name="MSE_6" value="WNL|Logical, linear, goal directed|Circumstantial|Circumstantial but redirectable|Tangential"] Insight/Judgement [checkbox name="insight" value="Good|Fair|Limited|Poor"] A/V Hallucinations: [checkbox name="MSE8" value="No history|Denied A/V hallucinations|Endorsed auditory hallucinations|Denied auditory hallucinations| Denied visual hallucinations|Endorsed visual hallucinations"]

ASSESSMENT

Patient's reported symptoms are consistent with:
[checkbox name="diagnosis" value="F41.1 Generalized Anxiety disorder|F43. 10 Post-Traumatic Stress Disorder|F32.9 Major Depressive Disorder, single episode, unspecified|F34.1 Persistent Depressive Disorder(Dysthmia)|F31.9 Bipolar Disorder,unspecified|F43.20 Adjustment disorder, unspecified|F90.0 Attention-deficit Hyperactivity Disorder, predominantly inattentive type|F90.1 Attention-deficit Hyperactivity Disorder, predominantly hyperactive type|F90.2 Attention-deficit Hyperactivity Disorder, combined type|F84.0 Autism Spectrum Disorder|F42 Obsessive Compulsive Disorder| F50.9 Eating Disorder,unspecified"] [text name="other" default=""]


Assessments completed and scores: 
[checkbox name="00" value="None"][checkbox name="PHQ" value= "PHQ9"][conditional field="PHQ" condition="(PHQ).is('PHQ9')"][text name="score1" default=""][checkbox name="GAD" value= "GAD7"][/conditional][conditional field="GAD" condition="(assessments).is('GAD7')"][text name="score2" default=""][checkbox name="PCL" value= "PCL5"][/conditional][conditional field="PCL" condition="(assessments).is('PCL5')"][text name="score3" default=""][/conditional][checkbox name="DES_" value= "DES"][conditional field="DES_" condition="(DES_).is('DES')"][text name="score4" default=""][/conditional][checkbox name="SCARED_" value= "SCARED"][conditional field="SCARED_" condition="(SCARED_).is('SCARED')"][text name="score5" default=""][/conditional][checkbox name="ASRS" value= "ASRS1.1"][conditional field="ASRS" condition="(ASRS).is('ASRS1.1')"][text name="score6" default=""][/conditional]

From the patient's report and therapist observation, patient is experiencing impairment in the following areas:
Sense of meaning: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s sense of meaning from life.
General wellbeing: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: [select name="functioning2" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="functioning3" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life. 
Family: [select name="functioning4" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: [select name="functioning5" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: [select name="functioning6" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability. 
Romantic relationships: [select name="functioning7" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships.

Patient displayed the following strengths and capabilities during the session: 
[checkbox name="strengths" value="motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions|ability to receive feedback from therapist|awareness of emotions|awareness and honesty around negative coping techniques|ability to tolerate painful feelings|openness to trying new, positive behaviors|having compassion for self"]
 

In sessions interventions provided:
[checkbox name="interventions2" value="----MOOD DISORDER INTERVENTIONS----|Active listening and feedback|Validated and normalized thoughts/emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Psychoeducation|Rapport building|Clarification|Reframing|Praise and encouragement|Reassurance|Assessment of client history|----ADHD----|Encouraging use of positive self-talk exercises|Exploration of time management skills|Exploration of organizational skills|Exploration of prioritization skills|Encouraging outside reading on ADHD/neurodivergence|Providing education about ADHD/neurodivergence|Identifying strengths/positive qualities|Exploration of social constructs|----COGNITIVE BEHAVIORAL THERAPY----|Introduction to the CBT model|Cognitive challenging|Cognitive restructuring|Identification/modification of dysfunctional assumptions/biases|Identification of distorted automatic thoughts|Reviewing negative thinking patterns|Identifying negative thinking patterns using examples from client's life|Reviewing 'feelings wheel'|Developing alternative thoughts and beliefs|Exploring how thoughts/beliefs influence mood and behaviors|----INTERPERSONAL INTERVENTIONS----|Exploration and education of communication skills to address interpersonal concerns|Education of assertive communication skills|Exploration of interpersonal patterns|Identifying and discussing boundary setting|Assisting client with practicing communication tools|----TREATMENT REVIEW----|Reviewing homework|Reviewing client's treatment plan and discussing progress towards goals|Goal setting|Administration of clinical assessments|Exploration of termination|Planning termination|Reviewing treatment frequency|----GENERAL INTERVENTIONS----|Reviewing family hx/dynamics|Role playing|Modeling|Problem-solving|Identifying/labeling emotions|Processing thoughts and feelings|Identifying negative coping and defense mechanisms|Providing psychoeducation on presenting concerns|Providing resources/literature to review|Identifying barriers to treatment/progress|----STRESS MANAGEMENT/COPING----|Provided psychoeducation on stress management interventions|Stress management intervention: deep breathing|Stress management intervention: PMR|Subjective Unit of Distress (i.e., SUDs)|Mindfulness practices|Grounding techniques|Identifying and planning enjoyable physical activities|Practicing progressive muscle relaxation|Guided imagery|Diaphragmatic breathing|----BEHAVIORAL HEALTH INTERVENTIONS----|Explored self-care strategies|Sleep hygiene interventions|Behavioral activation|Introduced SMART Goals|Identifying positive self affirmations|Identifying and reviewing positive coping skills|Identifying hobbies/values|Discussing benefits/effectiveness of medication|----MOTIVATIONAL INTERVIEWING----|Eliciting change talk|Eliciting alternative behaviors|Identifying pros/cons to change|Assessing readiness for change|----COUPLES & FAMILIES----|Parenting skills:exploring and reviewing effective parenting strategies|Exploration of family dynamics|Facilitating healthy expression of feelings/concerns|Identifying strengths/support system|Exploration of activities to enhance feelings of positive connection|Processing the aftermath of an argument or regrettable incident|Exploration of patterns of closeness and distance in the relationship|Exploration of couple's communication cycles|Observing and providing feedback on couple's communication and interactions|Exploration of family of origin/dynamics|Explored solvable and perpeptual problems|----DBT INTERVENTIONS----|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|Exploration of coping patterns|Exploration of emotions|Exploration of relationship patterns|Exploration of maladaptive cyclical patterns|Interpersonal interventions|Interactive feedback/process comments|Mindfulness|----TRAUMA & GRIEF/LOSS----|
Exploration of trauma and impacts on client's life|Exploration of potential reasons for behaviors/symptoms|Exploration of patterns of avoidance|Identifying consequences of avoidance|Providing psychoeducation on role avoidance plays in maintaining PTSD symptoms|Providing psychoeducation on PTSD symptoms|Identifying and processing issues around grief/loss|Exploration of trauma/abuse|Identifying triggers|Identifying alternative behaviors/coping skills that have helped in the past|Exploration and identifying strengths and support system"]
[checkbox name="EMDR" value= "EMDR"][conditional field= "EMDR" condition="(EMDR). is('EMDR')"][checkbox name="phases" value= "Phase 1|Phase 2|Phase 3/Assessment|Phase 4/Desensitization| Phase 5/Installation|Phase 6/Body Scan|Phase 7/Closure|Phase 8/reevaluation|Safe/Calm Place|Future Template|Resource Development and Installation|Container Exercise|Spiral Technique|Recent Event Protocol|Float Back Exercise"][checkbox name= "EMDR2" value= "NC"][text name="NC" default=][checkbox name= "EMDR3" value= "PC"][text name="PC" default=""][checkbox name= "EMDR4" value= "VOC Starting"][conditional field="EMDR4" condition="(EMDR4).is('VOC Starting')"][select name="EMDR5" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR6" value= "VOC Ending"][conditional field="EMDR6" condition="(EMDR6).is('VOC Ending')"][select name="EMDR7" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR8" value= "SUDS Starting"][conditional field="EMDR8" condition="(EMDR8).is('SUDS Starting')"][select name="EMDR9" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][checkbox name= "EMDR10" value= "SUDS Ending"][conditional field="EMDR10" condition="(EMDR10).is('SUDS Ending')"][select name="EMDR11" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][/conditional]

Patient's observable reaction to these interventions were: [checkbox name="reactions" value="positive|engaged|motivated| open|resistant|reluctant|negative|hesitant"]

Treatment progress:
Patient progress in achieving treatment goals is best assessed as [checkbox name="progress1" value="responding well to interventions|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|an increase in symptoms|a decrease in symptoms|minimal|stable|not enough infoirmation gathered to create treatment plan goals|identifying treatment plan goals"] as evidenced by patient self-report, observed behavior, and level of engagement.

PLAN

Changes in diagnosis or treatment plan: [text box="changes" value="None"]

Frequency of sessions:
[checkbox name="plan1" value="Weekly individual therapy.|Bi-weekly individual therapy.|Continue therapy sessions as needed.|Patient will contact therapist to schedule next session.|Therapist will contact patient to schedule next session."]

Plan for next session is to review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"]
Therapist will also follow up on [checkbox name="followup" value="activity scheduling|reframing/identifying cognitive distortions|mindfulness exercises|self care|spending time with others|prioritization/time management|setting/maintaining boundaries|utilization of communication tools|utilization of coping strategies|journaling|modifying eating/exercise habits|other"][text name="other" default=""]

Homework: Patient agreed to [text name="homework" default=""].

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to: [select name="neccessity" value="Address symptoms/achieve symptomatic relief.|Improve functioning in one or more life domains.|Maintain progress/prevent decompensation.|Prevent higher level-of-care/avoid hospitalization."]