SOAP.DAP Progress Note, Simplified

Met with patient. Patient reports doing [checkbox name="concerns" value="okay|better than last week|worse compared to last week|not so good"].

Patient notes experiencing [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"]. 

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="variable5" default=""].

[checkbox name="variable2" 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=" "]

Patient participates in assessment for safety/risk factors. Patient 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"].

Patient's reported symptoms are consistent with diagnostic criteria for:
[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=""]

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"].

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"]

Therapist [checkbox name="variable17" value="reviewed of homework|reviewed patient's treatment plan and had discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the patient'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 patient in problem-solving|processed patient'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 appraoches - emotion regulation skills|provided DBTapproaches - distress tolerance skills|provided DBT approaches - interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on improvement of sleeping habits|created a behavioral activation list with patient|explored trauma and impacts on patient'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"].

[checkbox name="cb12" value="Patient will identify treatment plan goals.|Patient begins to develop treatment plan goals.|Patient reviews/makes changes to treatment plan goals.|Patient will identify triggers that impact mental health symptoms.|Therapist builds therapeutic rapport with patient."]

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

Patient notes experiencing .

Patient discusses .

Patient participates in assessment for safety/risk factors. Patient endorses .

Patient's reported symptoms are consistent with diagnostic criteria for:

Patient displays .

Mental Status Exam:
Time: Affect:
Speech: Behavior:
Thought process:
A/V Hallucinations:

Therapist .

Therapist will Patient agreed to this plan.

Result - Copy and paste this output:

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