Simple Checkbox Progress Note

Met with [text name="firstname" default="Name"] [select name="mode" value="via SimplePractice Telehealth Platform|via secure telehealth|in person"]. Patient reports doing [checkbox name="concerns" value="okay|better than last meeting|worse compared to last meeting|not so good"]. [textarea name="update" default=" " rows="2"]
[checkbox name=[checkbox name="extended_reasons" value="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"] 
[var name="firstname"] 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"]. [textarea name="sx" default=" "  rows="2"]

[var name="firstname"] 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"]. [textarea name="themes" default=" " rows="2"].

[var name="firstname"] displays strengths including [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"].

[checkbox name="variable165" value="symptoms continue to wax and wane.|Client continues to remain sober.|Recent relapse.|Difficulty implementing tools/skills discussed"][text name="variable200" default=" " rows="2"]

[checkbox name="meds" value="Client denies current prescription of medication(s).|Client reports no changes to prescribed medication(s).|Client reports changes to prescribed medication(s).|Client notes"] [textarea name="medchanges" default=" " rows="2"]

[var name="firstname"] participated in assessment for safety/risk factors. Client endorses [checkbox name="variable7" value="no current suicide or homicide ideation|current suicide/homicide ideation|past suicide/homicide ideation|current suicide/homicide ideation with means but without plan or intent to act|past suicide/homicide attempt|recent suicide/homicide attempt|non-suicidal self-injury"].

[checkbox name="cb12" value="Reviewed client's treatment plan and discussed progress towards goals.|Client will identify treatment plan goals.|Client begins to develop treatment plan goals.|Client reviews/makes changes to treatment plan goals.|Client will identify triggers that impact mental health symptoms.|Therapist builds therapeutic rapport with client."]  [textarea name="12x" default=" " rows="2"]   

Therapist [checkbox name="variable17" value="reviewed of homework|discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the client's thoughts and feelings|engaged using open-ended questions|stated normalization/validation of thoughts and feelings|conducted therapeutic rapport building|provided encouragement and reassurance|reviewed family history/dynamics|provided role-play exercises|assisted client in problem-solving|processed client's thoughts and feelings|identified negative coping mechanisms|provided psychoeducation about mindfulness and meditation|provided relaxation skills|provided psychoeducation|identified and challenged cognitive distortions|practiced cognitive restructuring|reviewed self-care activities|stated positive affirmations|identified and/or reviewed positive coping skills|reviewed and practiced effective communication skills and assertiveness techniques|elicited change talk|explored and reviewed effective parenting strategies|processed the aftermath of an argument or incident|explored patterns of closeness and distance in relationships|explored couple's communication cycles|observed and provided feedback on couple's communication and interactions|provided DBT/emotion regulation skills|provided DBT/distress tolerance skills|provided DBT/interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on improvement of sleeping habits|created a behavioral activation list with client|explored trauma and impacts on client's life|explored patterns of conflict|explored potential reasons for behaviors/symptoms|identified and processed issues around grief/loss|identified triggers|identified alternative behaviors/coping skills that have helped in the past|identified and explored strengths and/or support system|utilized person-centered modalities|utilized EFT modalities|utilized ACT modalities|utilized motivational interviewing (MI) approaches"]. [textarea name="17x" default=" " rows="2"]

[var name="firstname"] will[checkbox name="cb12" value= "implement techniques discussed in session.|identify triggers that impact mental health symptoms|contact therapist to schedule next session."][text name="variable_2" default=" " rows="2"]

Therapist will [checkbox name="cb14" value="follow up with client in 1 week to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with client in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with client in 1-2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with client in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with client in 1 month to assess mood/functioning, and determine need for continued treatment or termination|begin termination process with client|client will contact therapist to schedule next session.|Therapist will contact client to schedule next session."]. [textarea name="plan" default=" " rows="2"] [var name="firstname"] agreed to this plan.
Met with . Patient reports doing .


firstname reports experiencing symptoms of .

firstname discusses .

firstname displays strengths including .

firstname participated in assessment for safety/risk factors. Client endorses .

Therapist .

firstname will

Therapist will .
firstname agreed to this plan.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.57, 29 form elements, 36 boilerplate words, 3 text boxes, 7 text areas, 12 checkboxes, 1 drop downs, 6 variables, 207 total clicks
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