Rachel progress note final2

Client Name: {FIRSTNAME} {LASTNAME} ({BIRTHDAY})
Appointment: {APPOINTMENTDATE} from {APPOINTMENTSTARTTIME} to {APPOINTMENTENDTIME}
Diagnosis: {DIAGNOSIS}
CPT Code: {CPTCODE}
POS Code: {POSCODE}
Client is a {AGE} self-identified [select name="variable_1" value="female|male|non-binary"] who presents today on HIPAA compliant Google Meet platform as client was attending from their home address. Participants in the session include this writer and the client.  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 establish; 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.

SUBJECTIVE/CHIEF COMPLAINT

Client expressed the following about the problem," [text name="variable_1" default=""]."
Ct continues to report symptoms consistent with {DIAGNOSIS} , including:
[checkbox name="variable_1" value="Depressed mood|Sadness|Loss of interest in pleasurable activities|Tearful or crying spells|Fatigue/low energy|Difficulty sleeping|Trouble falling asleep|Appetite changes|Trouble 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|Difficulty concentrating|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"]

Changes in medication: [text name="variable_1" default="None"]

Focus of session for today was:
[checkbox name="variable_1" value="Reviewed homework/assignment follow-up|Current symptoms/functioning|Symptom management|Management of depression symptoms|Management of anxiety symptoms|Self-esteem|ADHD|Friendships|Childhood/Family of Origin|Emotion dysregulation|Anger issues|Distress intolerance|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|Conflict with peers|Conflict with family|Conflict with coworker(s)|Self-Care/hygiene issues|Sleep hygiene|Physical activity/exercise|Coping strategies|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Trauma|Life Stressors|Stressor/coping mechanism(s)|Familial relationship distress|Work problems|Financial issues|Legal Issues|Housing issues|Parenting stress|Medical/health concerns|Medication concerns|Religious/spiritual concerns|Other"][text name="variable_1" default=""]

OBJECTIVE/MENTAL STATUS EXAM

Orientation: [select name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"]; Affect: [select name="MSE_2" value="Full range|Flat|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inapporpriate to mood and thoughtsRestricted in range and mood congruent"]; Speech: [select name="MSE_4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|soft"]; Behavior: [select name="MSE_5" value="WNL"]; Thought process: [select name="MSE_6" value="WNL|Logical, linear, goal directed|circumstantial|Circumstantial but redirectable|Tangential"]; SI/HI: [select name="MSE_7" value="Not indicated|denied|SI endorsed/HI denied"]

ASSESSMENT

SAFETY/RISK FACTORS
[checkbox name="variable_1" value="No SI/HI reported|Endorsed Suicidal Ideation|Endorsed passive SI|Endorsed Active Suicidal Ideation with a Method but without Plan or Intent to Act|Endorsed Suicide Attempt|Endorsed Nonsuicidal Self-Injury|No homicidal ideation reported"]

Symptoms are consistent with:
[checkbox name="variable_1" value="Anxiety disorders|Trauma and stressor related disorders|Depressive disorders|Adjustment disorders|Other"] [text name="variable_1" default=""]

From the client’s report and therapist observation, client is experiencing impairment in the following areas: 
General wellbeing: [select name="variable_1" 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="variable_1" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="variable_1" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life 
Family: [select name="variable_1" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection
Work: [select name="variable_1" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work
Economic: [select name="variable_1" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability 
Romantic relationships: [select name="variable_1" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships

The client displayed the following strengths and capabilities during the session: 
[checkbox name="variable_1" value="Awareness of emotions|Motivation to progress in treatment|Utilization of positive coping techniques|Utilization of positive coping techniques|Ability to express emotions|Willing to be vulnerable and ask for help from others at critical times|Awareness and honesty around negative coping techniques|Ability to tolerate painful feelings|Openness to trying new, positive behaviors|Seeking positive relationships|Having compassion for self"]
 
INTERVENTIONS/PLAN:

In sessions interventions provided:
[checkbox name="variable_1" value="reviewing homework|reviewing client's treatment plan and discussing progress towards goals|conducting assessments|setting appropriate boundaries |active listening|expressing empathy: expressed empathy for the client and explored client’s situation without judgment|open-ended questions|normalization of thoughts/feelings|validation|rapport building|positive reinforcement|clarification|reframing|praise and encouragement|reassurance|reviewing family Hx/dynamics|role playing|modeling|problem-solving|processing thoughts and feelings|identifying negative coping: identified negative coping mechanisms|mindfulness and meditation: provided psychoeducation about mindfulness and meditation|relaxation skills|provided psychoeducation|identifying and challenging cognitive distortions|practicing cognitive restructuring|planned and reviewed self care activities|identifying positive self affirmations|identifying and reviewing positive coping skills|reviewing and practicing effective communication skills and assertiveness techniques|eliciting change talk|eliciting alternative thoughts|parenting skills: exploring and reviewing effective parenting strategies|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|observe and provide feedback on couple's communication and interactions|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|providing education on sleep hygiene|behavioral activation|exploration of trauma and impacts on client's life|exploration of patterns of conflict|exploration of potential reasons for behaviors/symptoms|identified and processed issues around grief/loss|exploration of trauma/abuse|identifying triggers|identifying alternative behaviors/coping skills that have helped in the past|exploration and identification of strengths and support system"]

The client’s observable reaction to these interventions were: [checkbox name="reactions" value="Positive|Engaged| Open|Fearful|Resistant|Tearful|Negative|Hesitant|Motivated"]

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS

Client progress in achieving treatment goals is best assessed as - [checkbox name="cb12" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|reprenting relapse|an increase in symptoms|a decrease in symptoms|a significant excalation in symptoms|minimal|improving|stable"]
as evidenced by client self-report, observed behavior, and level of engagement.

Plan for next session:
[checkbox name="cb14" value="RTC in 1 week to assess mood/functioning, review homework, and goal setting|RTC in 2 weeks to assess mood/functioning, review homework, and goal setting|RTC in 1-2 weeks to assess mood/functioning, review homework, and goal setting|RTC in 2 weeks to assess relationship distress, review homework, and goal setting|RTC in 1 month to assess mood/functioning, review homework, and termination planning|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]
Ct agreed to [text name="variable_1" default=""]

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to:[select name="variable_1" 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"]
Client Name: {FIRSTNAME} {LASTNAME} ({BIRTHDAY})
Appointment: {APPOINTMENTDATE} from {APPOINTMENTSTARTTIME} to {APPOINTMENTENDTIME}
Diagnosis: {DIAGNOSIS}
CPT Code: {CPTCODE}
POS Code: {POSCODE}
Client is a {AGE} self-identified who presents today on HIPAA compliant Google Meet platform as client was attending from their home address. Participants in the session include this writer and the client. 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 establish; 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.

SUBJECTIVE/CHIEF COMPLAINT

Client expressed the following about the problem," ."
Ct continues to report symptoms consistent with {DIAGNOSIS} , including:


Changes in medication:

Focus of session for today was:


OBJECTIVE/MENTAL STATUS EXAM

Orientation: ; Affect: ; Speech: ; Behavior: ; Thought process: ; SI/HI:

ASSESSMENT

SAFETY/RISK FACTORS


Symptoms are consistent with:


From the client’s report and therapist observation, client is experiencing impairment in the following areas:
General wellbeing: 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: disruption to the client’s ability to engage and/or derive satisfaction from social connections.
Daily tasks: disruption to the client’s ability to perform daily necessary tasks for life
Family: disruption to the client’s satisfaction and stability in family life and connection
Work: disruption to the client’s satisfaction or productivity in the client’s function at work
Economic: disruption to the client’s financial stability
Romantic relationships: disruption to the client’s satisfaction from or ability to engage in romantic relationships

The client displayed the following strengths and capabilities during the session:


INTERVENTIONS/PLAN:

In sessions interventions provided:


The client’s observable reaction to these interventions were:

TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS

Client progress in achieving treatment goals is best assessed as -
as evidenced by client self-report, observed behavior, and level of engagement.

Plan for next session:

Ct agreed to

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.83, 29 form elements, 367 boilerplate words, 5 text boxes, 9 checkboxes, 15 drop downs, 203 total clicks
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