Progress Notes and Psychotherapy Notes

F-1

This Appendix covers two kinds of notes written about psychotherapy—progress notes and psychotherapy

notes—and highlights the practical value of this important distinction. Progress notes are part of the client

record or file, as noted below. Psychotherapy notes are not part of the file. After an overview of the client file or

record, the difference between these two kinds of notes is discussed along with guides for writing progress notes.

The Client File or Record

The record or file of a client’s treatment at the Clinic consists of:

 Contact information

 Informed consent for treatment (including notification of rights)

 An intake report and/or,

 A written treatment plan or case formulation based on an initial assessment (i.e. interview information,

formal assessment if used, and any other information collected from other sources)

 Progress notes documenting treatment, filed in reverse chronological order on the Clinic form Progress Note

 A termination note when work is concluded

 Other materials such as releases of information, test protocols, information obtained from other sources and

so forth.

 The file or record does not contain psychotherapy notes (see below). Another way of saying this is that if it’s

in the file, it’s not a psychotherapy note.

As context for progress notes versus psychotherapy notes, please also refer to the form in Appendix D Brief

Summary of Client Rights to Privacy and Access to Records and Consent to Behavioral Health Treatment and to

the document in that appendix entitled Protecting the Privacy of Your Behavioral Health Information.

A general intake outline is contained in Appendix C-4 Intake Outline and Report which can serve to organize

information and begin treatment planning. Treatment planning will, to some degree vary by supervisor and may

be organized around a diagnosis, a problem list, a set of treatment goals or a listing of directions for therapy.

Therapy notes (either progress notes or psychotherapy notes) may be easier to write and later to interpret if

written toward a good treatment plan.

Progress Notes versus Psychotherapy Notes: A Key Distinction.

Psychotherapy notes. Over the years, clinicians have debated about whether it was permissible to maintain a

second set of notes which was not available to anyone except the therapist. One of the few substantive changes

brought about by HIPAA is that psychotherapy notes are defined and are protected from normal release to the

client, the courts or anyone else. This distinction is sufficiently important that the clinician should be familiar

with the language of the federal regulation:

Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental

health professional documenting or analyzing the contents of conversation during a private counseling

session or a group, joint, or family counseling session and that are separated from the rest of the

individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring,

counseling session start and stop times, the modalities and frequencies of treatment furnished, results

of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment

plan, symptoms, prognosis, and progress to date. 45 CFR 164.501.

A later section (45 CFR 164.524) gives individuals almost unlimited access to their records, but specifically

excludes psychotherapy notes as defined above.

The key elements of this definition and its use are that psychotherapy notes:

 Are produced by a mental health professional

 Are separated from the rest of the medical record

 Don’t include the basic treatment and record-keeping that goes in a standard progress note, and

 Are not open to disclosure to the client or anyone else.

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Progress notes. Progress notes, then, are notes that are part of the regular file maintained in the Clinic.

Because many of the functions of notes for the purposes of the treating clinician can be accomplished through

psychotherapy notes, progress notes content can be kept to minimum. The following kinds of information go in

a progress note (further guidelines and examples appear below).

 counseling session start and stop times,

 medication prescription and monitoring

 the modalities and frequencies of treatment furnished,

 results of clinical tests, and

 any summary of the following items:

o Diagnosis,

o functional status,

o symptoms,

o prognosis, and

o progress to date.

Who Is The Audience?

In any writing project, the first and most important question is “who is the audience?” Throughout the writing

process, one must step back occasionally and hear what is written using the ears of the potential audience(s).

Often, as with the notes we’ll be discussing here, there will be multiple audiences and you must keep each of

them in mind while writing. Here is a listing, intended to be in order of likelihood, of those who will see and use

progress notes:

 You, the therapist, will look back at the notes as needed in the course of treatment.

 The client or patient may want to look at the notes and the contents of the file and has this right under

New Mexico guidelines and HIPAA regulations

 Another therapist who picks up the case at the Clinic or in another setting (with appropriate release of

information).

 An evaluator for another agency may review therapy notes, again with the client’s permission

 An attorney representing your client or (perhaps more importantly) an opposing attorney in a legal

proceeding (this may be by release of information or through a “hidden permission” in a law suit claiming

damages for “pain and suffering”—see the Clinic’s document Protecting the Privacy of Your Behavioral

Health Information).

These various potential readers of your notes create different concerns and expectations for the contents of your

notes. What will be most useful to you in the future may very well not be what you would want your client to

read and a note that works for you and your client may not be something you’d want in the hands of a attorney

hostile to your client’s interests. You won’t know as you write which audience will see your notes, but need to

keep in mind that you are writing for these different readers.

This is not, in practice a difficult task. First, keep in mind that your task in a progress note is to document

that reasonable work occurred toward the goal of helping the client with her or his issues. Your note can be

brief; to the extent that you can relate that day’s work to treatment issues and methods you’ve defined previously

in a treatment plan, the easier your documentation will be. Keep track of significant events—changes in

medications, life events, names of important people that come up—that you will want to be able to easily

reference in the future. As noted in the formats described below, include brief assessments of the client’s status

and progress as appropriate and remind yourself of plans you have for future sessions (homework assignments,

topics to follow up on).

Leave longer thoughts, queries and reflections for your psychotherapy notes. The advantage that psychotherapy

notes give us is that you can record any hypotheses, personal reactions, doubts, possible interpretations,

supervisory recommendations, etc. in a form that will be maximally useful for you.

Where Are The Two Kinds Of Notes Kept?

In general, progress notes will be written immediately following a session and will be kept in reverse

chronological order in the client’s file locked in the appropriate drawer in the Clinic. The client’s file may be

removed only for purposes of writing and reviewing notes and replaced when you are finished. Supervisors will

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come to the Clinic to review files periodically (at least each semester). If an occasion arises in which you want to

remove the file from the Clinic, you need permission of the Clinic Director and need to put a check-out card

where the file was so that staff know it is out. If you are in possession of a file, you are responsible for

maintaining its confidentiality—keep it in your possession or keep it in a secure place.

Psychotherapy notes must be kept separate from the main file. That could be in a different locked drawer at the

Clinic (but never in the top drawer where active files are kept). It is likely that these are the notes you’ll want

with you for supervision and preparation for sessions, so you may keep them in your possession. If so, you must

assure that confidential information is protected by securing these files in your home or office. Each clinician

should develop habits and methods of protecting confidential information, for instance, psychotherapy notes and

testing files that you may want in your possession and care outside the Clinic building.

A note regarding assessment files is in order at this point. You may be keeping assessment materials with you

for scoring and writing outside the Clinic. The safest way to preserve confidentiality and secure the file is to keep

name identification out of the file until you finalize it in a report. Then secure the original file and all materials

at the Clinic.

Styles Of Progress Notes

The following are some suggestions for the content of progress notes:

1. Use the Clinic’s standard Progress Note form (Appendix F-2) to provide the basic information about who

was seen when by whom, for how long and for what purpose. Payment is recorded on this form as well in

addition to the receipts filled out for the client and the Clinic.

2. The note may be brief but should include a description of the major events or topics discussed, specific

interventions used, your observations and assessment of the client’s status, and any plans you may have

for the future.

3. It is not necessary that these notes be extensive. In fact, in future practice when time is of the essence,

brevity and capturing the essence of the treatment in a session will be necessary. Two examples of

structured systems for progress note writing are listed briefly below with references to more complete

descriptions.

Compared to psychotherapy notes. By their nature, psychotherapy notes can be in any form that is useful to

you and need not be readable by others (e.g. use of your own personal shorthand is acceptable). Think of

psychotherapy notes as a form of self-consultation and preparation for supervision. It is here that you may feel

free to detail what happened in a session in order, put your thoughts and feelings about what was going on, list

hunches and hypotheses to explore further, and write questions to bring up with your supervisor. You may also

want to jot notes from your supervisory session that you want to include in your thinking for future sessions.

D(R)AP format for progress notes. In hospital settings, the most common guideline for notes is the SOAP

format (Subjective, Objective, Assessment, Plan) described briefly below. Many practitioners have found the

SOAP format awkward or forced for recording progress in psychotherapy. The preferred format for notes at the

Clinic uses the acronym DAP (Description, Assessment and Plan). Baird (2002) suggests a similar format and

his thoughts on clinical documentation are useful. In a typical therapy session, a client may bring up two or

three therapy-significant events or issues or describe the activity of carrying out a homework assignement. Each

may be briefly documented in the DAP format.

Description, as Baird elaborates, provides information as to who was involved, where, and when a significant

event occurred. It could also be a description of an issue of personal importance discussed by the client and

how they experienced the event. A description could also be the way a client carried out an assignment and the

difficulties or success they experienced. Baird includes a separate section (R for Response) for what the clinician

does in response to the client’s issue. We recommend that clinician behavior be woven into description.

Response (per Baird) is what you did after listening and observing and reflecting on what the client brought to

the session. This may be an interpretation offered, a clarification, information given, a homework assignment, a

challenge to narrow thinking about an issue, formal problem solving around the event, empathetic/supportive

behavior on your part, functional analysis of a situation, a normalizing comment, or whatever is appropriate

from the therapeutic conceptualization you are using. If the situation is a serious one involving detailed

F-4

assessment of danger or legal issues, you would document what you did in whatever detail is necessary to show

that you attended to the issues involved.

Assessment is your understanding of what the event means if you know. Baird recommends thinking about how

the event or behavior relates to precipitating factors, to previous behavior, to other events in the client’s life, to

the treatment plan. The important part of this aspect of your thinking and writing is your reflection on the

events in the client’s life in terms of treatment. Assessment may also record your observations about the client’s

physical or emotional state and such factors as severity of symptoms, riskiness of behavior, dangerousness,

suicidality and so forth

.

Treatment Plan is your plan for future treatment. Baird notes that this may be as brief as “Scheduled for next

Wed”. If you give homework assignments or want to note topics to follow up on or actions to take before the next

session, they can be entered here as reminders.

Examples of DAP notes are given on the Clinic website.

SOAP format notes. SOAP is an acronym for Subjective-Objective-Assessment-Plan and is a part of Problem

Oriented medical records developed by L. L. Weed (see Cameron and Turtle-song, 2002 on the Clinic webpage for

a fuller description). This method was developed in the medical setting to standardize entries in the patient file

(e.g. S(ubjective): “Patient complained of …”; O(bjective): Blood pressure, lab results, results of physical

examination; A(ssessment): clinical diagnosis of symptoms; P(lan): prescriptions, treatments recommended, etc.).

In psychology practice, Assessment and [Treatment] Plan are similar to what Baird describes.

The SOAP format is widely used especially in hospital settings and is required in some agencies for psychological

and psychiatric progress notes as well as medical notes. But some have noted (e.g. Baird, 2004) that the format

it may become arbitrary or rigid, for instance, what material goes in which section. It is especially difficult in

psychotherapy to sort out what is objective and what is subjective and the meaning of events may be lost.

Student-clinicians may find this format useful, however, and examples are given on the Clinic website.

Unformatted notes. Clinicians may write notes in a less or differently structured fashion, such as integrating

Baird’s sections in a narrative form, providing a chronological sequence of events in a session (process notes) or

referring notes to specific issues in the treatment plan. The above discussion, and additional reflection on one’s

own treatment approach, may stimulate the student to develop their own format for notes that better suit their

method and style. Students are encouraged to discuss with their supervisor approaches to progress notes.

Psychotherapy Notes: Reprise

The greater protection provided to psychotherapy notes by HIPAA regulations may allow student-clinicians

greater latitude to abbreviate their progress notes and expand on the reflection, reactions, thoughts and feelings

that may safely be recorded in psychotherapy notes. To return to an earlier theme, the primary audience for

psychotherapy notes is yourself: your client acknowledges in the Clinic’s consent for treatment that such notes

may be kept and are not available for client inspections. This allows you greater freedom to reflect on difficulties,

hunches and questions and make these written reflections a greater learning experience in the context of your

supervision.

Suggested Readings

Baird, B. N. (2004) The Internship, Practicum, and Field Placement Handbook: A Guide for the Helping Professions

(4

th

ed.). Prentice Hall

Cameron, S. & turtle-song, i. (2002) Learning to write case notes using the SOAP format. Journal of Counseling &

Development, 80, 286-292.

Wiger, Donald E. (1999) The Clinical Documentation Sourcebook: A Comprehensive Collection of Mental Health

Practice Forms, Handouts, and Records (2

nd

ed.). Wiley.

Zuckerman, E. L. (2005) Clinician's Thesaurus: The Guide to Conducting Interviews and Writing Psychological

Reports (6

th

ed.). Guilford Press.

Psychotherapy Progress Note

Psychiatric Social Worker

Date of Exam: 4/28/2012

Time of Exam: 9:00:56 AM

Patient Name: Conner, Andrea

Patient Number: 1000010644560

Improvement is occurring. "My social life now revolves around exercise instead of drinking with my friends."

Problem Pertinent Review of Symptoms:

Feelings of anxiety are denied. Andrea denies experiencing dysphoric moods. Sleep disturbance is not reported. Andrea describes rare

substance cravings. She denies the temptation to use. Andrea denies use. Andrea reports that she has been regularly attending AA

meetings. A sample for urine drug screening was obtained. She has maintained sobriety. Impulsive behaviors are not reported.

Content of Therapy: The patient's substance abuse problems were the main issue this session. Feelings of shame were also

expressed.

Therapeutic Interventions: The focus of today's session was on helping the patient increase insight and understanding. The main

therapeutic techniques used involved the exploration of the patterns of certain behaviors. Therapeutic efforts also included aiding the

patient in identifying the precipitants of unproductive feelings and behaviors. . The importance of abstinence was also reviewed.

MENTAL STATUS: Andrea is alert, attentive, casually groomed, and relaxed. She exhibits speech that is normal in rate, volume, and

articulation and is coherent and spontaneous. Language skills are intact. Mood is entirely normal with no signs of depression or mood

elevation. Affect is appropriate, full range, and congruent with mood. Insight into illness is normal. Social judgment is intact. Signs of

chemical withdrawal are exhibited by Andrea. Mild signs of anxiety which appear to be secondary to withdrawal are present.

DIAGNOSES: The following Diagnoses are based on currently available information and may change as additional information

becomes available.

Axis I: Alcohol Abuse, 305.00 (Active)

INSTRUCTIONS / RECOMMENDATIONS / PLAN:

Link to Treatment Plan Problem: Substance Abuse

Short Term Goals:

Andrea will make plans for a recreation activity that does not involve alcohol or drugs, within one week.

Target Date: 4/29/2012

---------------------------------

Excellent progress in reaching these goals and resolving problems seemed evident today.

Recommend that the interventions and short term goals for this problem be re-written at the next Treatment Team meeting.

--------------------------------

Return 2 weeks or earlier if needed.

NOTES & RISK FACTORS:

History of Subst. Abuse

90806 PSYTX, Office, 45-50 MIN

Time spent counseling and coordinating care: 45-50 min

Session start: 9:00 AM

Session end: 9:50 AM

John Smith, LCSW

Electronically Signed

By: John Smith, LCSW

On: 4/22/2012 11:07 AM

INTAKES,PROGRESSNOTES,&PYCHOTHERAPYNOTES



Therapistsneedtoensurethatdocumentationinrecordsisaccurateandreflects

the services provided.The records document profession work in order to

facilitate provision of services by the therapist or other professionals, to ensure

accountability,continuityofcare,andtomeetotherrequirementsofinstitutions

orthelaw.

Therapists’

records, in general, fall in three categories (Intakes, Progress Notes,

and Psychotherapy Notes).Other records are usually evaluations for specific

purposes(e.g.,ForensicorNeuropsychologicalEvaluations).Theintakeandnotes

arediscussedbelowwithcontentsuggestions.

Progress Notes and Psychotherapy Notes differ and are afforded different

degrees of privacy under the

 law.The Health Information Portability and

Accountability Act (HIPAA) protects the privacy of Psychotherapy Notes.The

differencesareexplainedbelow. 



INTAKES

An IntakeAssessment should helpthe therapistconceptualize the problems and

treatment.Biological, psychological and sociocultura l  functioning  should be

documented.The evidence should be integrated in a manner designed to

maximize treatment effectiveness. A good intake should reflect the therapist’s

appreciationforthepersoninhisorherentirety.Incaseofaminor,atherapist

maywishtogetinformationfrommultiplepartiesincludingteachers,parentsand

siblings.While intakes differ among therapists, there should be commonalities

that

run throughout.An example of an intake form covering relevant areas is

presentedbelow.



INTAKEASSESSMENT(EXAMPLE)



Patient:

DateofBirth:

IntakeDate:

PresentingProblem(s):_______________________________________________

___________________________________________________________________

PresentingSymptoms:_______________________________________________

___________________________________________________________________

PresentingProblemHistory:___________________________________________

___________________________________________________________________

FamilyHistory:______________________________________________________

___________________________________________________________________

EducationandOccupationalHistory:____________________________________

___________________________________________________________________

MedicalProblems:___________________________________________________

CurrentPrescriptionMedications:

Name:________________________________

Dosage:_______________________________

EstimatedStartDate:____________________

Alcohol,Nicotine,andDrugHistory:

_____________________________________

___________________________________________________________________

MentalHealthTreatmentHistory(Patient&Family):_______________________

LegalHistory:_______________________________________________________

SpiritualLife:_______________________________________________________

Exercise:___________________________________________________________

MentalStatus:______________________________________________________

(Thisshouldprovideabasisforunderstandingthepatient’spresentation)______

a. Appearance

b. MannerandApproach

c. Orientation,AlertnessandThoughtProcesses

d. Mood&A ffect(Includingsuicidaland/orhomicidalideation

SummaryandConclusions:____________________________________________

___________________________________________________________________

TreatmentRecommendationsandPrognosis:______________________________

Diagnoses:

AxisI:_____________________________________________________________

AxisII:____________________________________________________________

AxisIII:____________________________________________________________

AxisIV:____________________________________________________________

AxisV:____________________________________________________________

Current___________

 HighPreviousYear____________________



SignatureandLicense



PROGRESSNOTES

Progress notes summarize sessions, are part of the medical record, and do not

require the patient’s authorization for disclosure. They can be released to the

patient and third party payers. Progress notes contain the following types of

information.

a. Dateofsession

b. Startandstoptimes 

c. Modality

oftreatmentprovided

d. Medicationprescriptionandmonitoring

e. Anysummaryofthefollowingitems:

 Diagnosis

 Functionalstatus

 Symptoms

 Prognosis

 Progress

 Suicidalorhomicidalideation

 Nextappointment

AnexampleofaProgressNoteForminshownbelow.



PROGRESSNOTES(EXAMPLE)



Patient:

Date:

Start&StopTime:

TreatmentModality:_________________________________________________

ProblemsAddressed:

___________________________________________________________________

Progress:

___________________________________________________________________

Suicidal&HomicidalIdeation:

___________________________________________________________________

ScheduledAppointment:______________________________________________



SignatureandLicense



PSYCHOTHERAPYNOTES

Psychotherapy notes are treated differently than other medical records.

Psychotherapy notes, according to HIPAA, are protected from normal release to

the patient, the courts  or anyone else, unless stipulated by state law.The key

elementsofpsychotherapynotesare:

 Theyareproducedbyamentalhealthprofession



Theyareseparatedfromtherestofthemedicalrecord

 Theydon’tincludethebasictreatmentandrecord‐keepingthatgoesin

astandardprogressnote

Bytheirnature,psychotherapynotescanbeinanyformthatthetherapistwants.

Theycanbeusedtodetailwhathappened

inasession.Theycanbereviewedto

produce hunches andhypothesis and help directtherapy. Issuescan be detailed

thatthetherapistwouldwanttokeepprivate. 

APPLESEED COMMUNITY MENTAL HEALTH CENTER, INC.

COUNSELING PROGRESS NOTE

Rev 03/2010

ACMHC COUNSELING PROGRESS NOTE

Page 1

of

1

Client Name (First, MI, Last)

Client No.

Others Present at Session: If others present, please list name(s) and relationship(s) to the client:

Client Present Client No Show/Cancelled

Stressor(s)/ Significant Changes in Client’s Condition (for face-to-face visit)

No Significant Change from Last Visit

Mood/Affect

Thought Process/Orientation

Behavior/Functioning

Substance Use

Danger to:

None Self Others Property

Ideation Plan Intent Attempt Other:

Goal(s)/Objective(s):

Therapeutic Intervention and Progress Toward Goal/s:

Recommendation for Modification and Update of the ISP if Applicable:

Provider Signature/Credentials

Date

Supervisor Signature/Credentials (if needed)

Date

Medicare “Incident to” Services Only

Supervisor Signature/Credentials (if needed)

Date

Supervisor Consultation (if needed)

Date of

Service

Staff ID

No.

Loc.

Code

Prcdr.

Code

Mod

1

Mod

2

Mod

3

Mod

4

Start

Time

Stop

Time

Total

Time

Diagnostic

Code

APPLESEED COMMUNITY MENTAL HEALTH CENTER, INC.

COUNSELING PROGRESS NOTE

Rev 03/2010

ACMHC COUNSELING PROGRESS NOTE

Page 1

of

1

Client Name (First, MI, Last)

Betty Borderline

Client No.

5.0.5.

Others Present at Session: If others present, please list name(s) and relationship(s) to the client:

Client Present Client No Show/Cancelled

Stressor(s)/ Significant Changes in Client’s Condition (for face-to-face visit)

No Significant Change from Last Visit

Mood/Affect

Thought Process/Orientation

Behavior/Functioning

Substance Use

Danger to:

None Self Others Property

Ideation Plan Intent Attempt Other:

Goal(s)/Objective(s): Goal 1/objective 1

Therapeutic Intervention and Progress Toward Goal/s: Client reported she had strong thoughts of self-harm this week but had not

acted on them. I asked how she had done this and labeled the skills she had used to assist her in circumventing these thoughts.

Affirmed validated her feelings noting she had done this without the people who usually are available to help her get through these

difficult times. Discussed the reason for thoughts of self-harm to increase awareness of when thoughts could re-occur in order to plan

to effectively manage these thoughts. Client commended for gaining the ego-strength to counteract urges to harm herself. Client

recognized her dysfunctional thoughts were, in part, the result of a disrupted routine that created anxiety which triggered self-

injurious thoughts. Client states that she does not currently have thoughts of self –harm.

Recommendation for Modification and Update of the ISP if Applicable: NA

Provider Signature/Credentials

Thomas Therapist, LPC

Date

12/23/10

Supervisor Signature/Credentials (if needed)

Date

Medicare “Incident to” Services Only

Supervisor Signature/Credentials (if needed)

Date

Supervisor Consultation (if needed)

Date of

Service

Staff ID

No.

Loc.

Code

Prcdr.

Code

Mod

1

Mod

2

Mod

3

Mod

4

Start

Time

Stop

Time

Total

Time

Diagnostic

Code

12/23/10

007

11

15

HE

-

1:00

-

:60

301.83

BELLEFAIRE JCB

OUTPATIENT TRAUMA FOCUS COGNITIVE BEHAVIORAL THERAPY (TFCBT) PROGRESS NOTE

CASE TYPE: WRAP TFCBT; JOP/WRAP TFCBT; OUTPATIENT TFCBT; SCHOOL BASED TFCBT

Client Name:(Last, First) Client #: Date of service:

Staff ID, Name:

Client Start Time

: PM

Client End Time

: PM

Billable Time

0.00 UNITS

Staff Start Time

: PM

Staff End Time

: PM

Total Time

0.00 UNITS

Program RU

<

Location

< Other:

Modifier

<

ISP GOAL(S) ADDRESSED: #1 ; #2 ; #3 ; #4

INTERVENTION

PSYCHOEDUCATIONAL: CLIENT

PSYCHOEDUCATIONAL: PARENT

RELAXATION SKILLS

>

AFFECT EXPRESSION

COGNITIVE COPING TECHNIQUES

INVIVO DESENSITIZATION

>

Narrative therapy techniques

Safety planning

Identify and correct cognitive distortions

Preparation of child for sharing narration with parent using CBT and client centered techniques

Other:

Identify and correct cognitive distortions

Behavior management techniques

Preparation of parent for sharing of narration

Other:

Briefly Describe:

Progress: N/A No Change Deterioration Improvement: If Deterioration or Improvement Noted, Briefly

Describe

Significant Life Changes/Events: N/A Yes, Explain:

Recommend Modification to ISP: No Yes, refer to MHA Update

Change in Risk to Self or Others: No Yes, refer to MHA update; Suicide Assessment; Duty to Protect

My signature verifies that service occurred as documented on this progress note. I authorize Bellefaire/JCB to bill for the time documented as “billable” above.

________________________________________________________________ __________________________ _________________________

STAFF SIGNATURE CREDENTIAL DATE

________________________________________________________________ __________________________ ________________________

SUPERVISOR SIGNATURE (If Applicable) CREDENTIAL DATE

Conversion chart: >

March 2010

BELLEFAIRE JCB

BEHAVIORAL HEALTH COUNSELING

OUTPATIENT TRAUMA FOCUS COGNITIVE BEHAVIORAL THERAPY (TFCBT) PROGRESS NOTE

CASE TYPE: WRAP TFCBT; JOP/WRAP TFCBT; OUTPATIENT TFCBT; SCHOOL BASED TFCBT

Client Name:(Last, First) Klinesmith Client #: Emily Date of service: 3/2/2010

Staff ID, Name: 5089 Katie, Koncilja, LPC

Client Start Time

01:15 PM

Client End Time

02:10 PM

Billable Time

0.92 UNITS

Staff Start Time

01:15 PM

Staff End Time

02:10 PM

Total Time

0.92 UNITS

Program RU

624 BHC

Location

03 School Other:

Modifier

F0 F:F w/Client(IP)

ISP GOAL(S) ADDRESSED: #1 ; #2 Goal 2) Michelle will demonstrate improved coping skills to better manage difficult feelings,

including those surrounding her history of trauma, as evidenced by guardian and school reports of rule compliance and improved scores in the areas of arguing

with others, getting into fights, yelling, screaming, fits of anger, breaking rules, lying, can’t sit still, feeling lonely, having nightmares and breaking the law on her

Ohio Scales. ; #3 Goal 3) Michelle will improve her communication skills as evidenced by family reports of improved satisfaction in relationship with IP

and improved scores in the areas of arguing, fights, yelling and screaming, fits of anger, breaking rules, lying, feeling lonely and breaking the law on IPs Ohio

Scales. ; #4

INTERVENTION

PSYCHOEDUCATIONAL: CLIENT

PSYCHOEDUCATIONAL: PARENT

RELAXATION SKILLS

Rationale for completing narrative

>

AFFECT EXPRESSION

COGNITIVE COPING TECHNIQUES

INVIVO DESENSITIZATION

Feeling Identification

Cognitive positive self talk

Exploration development of self efficacy

Narrative therapy techniques

Safety planning

Identify and correct cognitive distortions

Preparation of child for sharing narration with parent using CBT and client centered techniques

Other:

Identify and correct cognitive distortions

Behavior management techniques

Preparation of parent for sharing of narration

Other:

Briefly Describe: Ip stated that she feels alright about starting her trauma narrative. IP stated an understanding of why the trauma

narrative will be used. IP did very well writing out her positive internal traits paragraphs and appears to be getting better with her

impulsivity of crossing things out quickly. As IP was writing her positive traits this worker assisted in the identification of

cognitive distortions and turning negative statements into positive ones.

Progress: N/A No Change Deterioration Improvement: If Deterioration or Improvement Noted, Briefly

Describe

Significant Life Changes/Events: N/A Yes, Explain:

Recommend Modification to ISP: No Yes, refer to MHA Update

Change in Risk to Self or Others: No Yes, refer to MHA update; Suicide Assessment; Duty to Protect

My signature verifies that service occurred as documented on this progress note. I authorize Bellefaire/JCB to bill for the time documented as “billable” above.

________________________________________________________________ ________LPC______________ _____3/12/10______________

STAFF SIGNATURE CREDENTIAL DATE

________________________________________________________________ __________________________ ________________________

SUPERVISOR SIGNATURE (If Applicable) CREDENTIAL DATE

Conversion chart: >

March 2010

Counseling Progress Note 2010-04-01

Client Name: Client ID:

Staff Name: Staff ID:

Date of Service

Start

Time

□ am

□ pm

End

Time

□ am

□ pm

M M D D Y Y Y Y

Program: CTU Counseling

Team: Service Code: H0004

□HE-face-to- face □ HQ-group

# in group

Client Location

(check only one)

□ 53-GCB □ 12-Client Home □ 99-Community □ 51-Summit □09-Incarcerated □ UK- client not present

Date entered:

Observed/Reported changes in condition:

None

Stressors/Extraordinary Events:

None No significant change from last visit

Client Condition

Appearance

unusual/bizarre

poor hygiene

appropriate casual and neat fastidious appears younger

apprehensive

inappropriate unkempt disheveled appears older

other:

Behavior

cooperative guarded aggressive passive agitated

unusual/bizarre impulsive fearful dramatic other:

Stream of Thought

clear & coherent impoverished rapid flight of ideas incoherent

fragmented disordered loose tangential other:

Abnormalities of Thought Content

none phobias concrete thinking paranoid ideation delusions

overvalued ideas ideas of reference poverty of thought obsessions other:

Perceptual Disturbances

none

depersonalization derealization auditory visual

illusions tactile olfactory other:

Affect

appropriate inappropriate expansive guilty bright

congruent incongruent labile heightened depressed

full range constricted blunted flat other:

Mood

euthymia elevated euphoria angry/irritable apprehensive

anxious depressed dysphoria apathetic other:

Orientation

oriented x 3 not time not place not person

Insight

present adequate limited impaired faulty

Judgment

good fair impaired poor grossly inadequate

Affix STAFF label Affix CLIENT label

Greater Cincinnati Behavioral Health Services

Counseling Progress Note

Counseling Progress Note 2010-04-01

Client Name: Client ID:

Issue(s) presented today:

symptoms or impairment such as attitudes about illness:

early life experiences:

emotional distress:

maladaptive behavior patterns:

personality growth and development:

stabilization of mental status or functioning:

issues related to establishing therapeutic relationship:

coping strategies or techniques:

other:

Goal(s)/Objective(s) Addressed from ISP:

Recommended Revision to ISP: None Revise ISP

Therapeutic interventions provided OR Group Topic/Activity/Intervention

Response to intervention/Progress toward goals OR Group Participation

Additional information/Plan

Provider Signature/Credential: Date:

Client Signature (Optional Based on Client Preference):

Date: _____________

Counter-Signature/Credential: Date:

Date/Time of next

Appointment:

Client rating of progress: (write number in box)

Have you made progress toward your goals today?

( Not Rated = 0; None = 1 Some Progress = 2; or Good Progress= 3

Affix CLIENT label

Greater Cincinnati Behavioral Health Services

Counselin

g

Pro

g

ress Not

e

OUTPATIENT PSYCHIATRIC CLINIC

2121 Main Street

Raleigh, NC 27894

919-291-1343

Date of Exam: 3/13/2012

Time of Exam: 10:45 am

Patient Name: Smith, Anna

Patient Number: 1000010544165

TREATMENT PLAN FOR ANNA SMITH

Treatment Plan Meeting

A Treatment Plan meeting was held today, 3/13/2012, for Anna Smith.

Diagnosis:

Axis I: Generalized Anxiety Disorder, 300.02 (Active)

Axis II: None V71.09

Axis III: See Medical History

Axis IV: None

Axis V: 60

Current Psychotropics:

Paxil 10 mg PO QAM

Buspirone 10 mg PO QAM

Ambien CR 6.25 mg PO QHS

Synthroid 50 mcg PO QAM

Problems:

Problem #1: anxiety

________________________________________________________________________

Problem = ANXIETY

Anna's anxiety has been identified as an active problem in need of treatment. It is primarily manifested by:

Generalized Anxiety Disorder - with excessive worrying - with impairment in functioning.

Long Term Goal(s):

- will reduce overall level, frequency, and intensity of anxiety so that daily functioning is not impaired.

Target Date: 4/25/2012

Short Term Goal(s):

Anna will have anxiety symptoms less than 50% of the time for one month.

Target Date: 4/25/2012

In addition, Anna will exhibit increased self-confidence as reported by client on a self-report 0-10 scale weekly for two months.

Target Date: 5/13/2012

Intervention(s):

• Prescriber to monitor side effects and ADJUST MEDICATION DOSAGE to increase effectiveness and decrease SIDE EFFECTS, as appropriate for

anxiety disorder once per week for one month.

Comprehensive Treatment Plan Barriers

Emotional problems interfere with treatment.

- Anna is fearful that her apprehensive symptoms will never be under good control.

Comprehensive Treatment Plan Strengths

Anna's strengths include:

cognitive

- Intellectually bright

communicative

- Has good communicative skills

family

- Good relationship with family

________________________________________________________________________

Upon completion of Long Term Goal, Discharge or Transition Plan includes:

Continue with current therapist: Name _____________________________________

Continue with current psychiatrist: Name _____________________________________

Refer for follow up with: Name _______________________ Arranged by: ___________

Other: ________________________________________________________________

Signature below indicates that this Treatment Plan has been reviewed and approved:

Date:________ Clinician: _____________________________ Title:_______________

Date:________ Clinician: ______________________________Title:_______________

Date:________ Clinician: _____________________________ Title:_______________

Date:________ Patient: ____________________________________

Date:________ Parent/Guardian: __________________________________________

Date:________ Other: ___________________________________________________

A copy of this treatment plan was: _____ given to the patient/family OR _____ declined by the patient/family.:

Date:________ Clinician: _____________________________ Title:_______________

Elizabeth Lobao, MD

Electronically Signed

By: Liz Lobao, MD

On: 3/13/2012 10:48:09 AM

PSYCHIATRIC HOSPITAL

1234 Main Street

Anywhere, USA

Date of Exam: 6/29/2012

Time of Exam: 1:33:31 PM

Patient Name: Jennifer Smiley

Patient Number: 1000010645495

TREATMENT PLAN FOR JENNIFER SMILEY

Treatment Plan Meeting

A Treatment Plan meeting was held today, 6/29/2012, for Jennifer Smiley.

Diagnosis:

Axis I: Major Depressive Disorder, Single, Severe w/o Psychotic Features, 296.23

(Active)

Alcohol Dependence, 303.90 (Active)

Axis II: Deferred Diagnosis 799.99

Axis III: See Medical History

Axis IV: Primary Support Group

Occupational

Grief: Death of daughter in 2011

Axis V: 50

85 (Highest GAF in past 12 months)

Current Psychotropic:

#1) Prozac 30 mg. PO QAM

#2) Antabuse 250 mg. PO QAM

#3) Synthroid 100 mcg. PO QAM

#4) Ambien CR 6.25 mg PO at Hour of Sleep

Problems:

Problem #1: depressed mood

___________________________________________________________________

Problem = DEPRESSED MOOD

Jennifer's depressed mood has been identified as an active problem in need of treatment. It is primarily manifested by:

Thoughts of death or suicide - experienced almost daily.

Long Term Goal(s):

- Will score within normal Limits on the Beck Depression Scale.

- Will maintain compliance with psychotropic medications.

Target Date: 9/12/2012

Short Term Goal(s):

Jennifer will recognize and report thoughts of death to staff daily for one week.

She will attend daily grief support group.

She will attend 3 recreation activities per week.

Target Date: 5/1/2012

Intervention(s):

• Prescriber will examine patient and order consultations and lab as needed to arrive at all appropriate DIAGNOSES

• Prescriber to prescribe medications, monitor side effect, and adjust dosage to STABILIZE MOOD and minimize side effects.

• Prescriber will educate patient (patient's family) as to the RISKS AND BENEFITS of treatment and obtain informed consent, if

appropriate.

• Therapist will provide emotional SUPPORT and encouragement, and help patient focus on sources of pleasure and meaning.

Status:

6/29/2012: The undersigned therapist met with the patient on the date above in a face to face meeting to work with him/her in

developing this Treatment Plan.

________________________________________________________________________

Comprehensive Treatment Plan Barriers

Emotional problems interfere with treatment.

- Emotional problems will be dealt with via treatment plan.

- Jennifer is encouraged to keep a personal journal to assist in sorting out her thoughts and goals.

Comprehensive Treatment Plan Strengths

Jennifer's strengths include:

Cognitive

- Intellectually bright

- Can make needs known

Physical

- Is physically healthy

________________________________________________________________________

Upon completion of Long Term Goal, Discharge or Transition Plan includes:

Expected length of stay: 7 days

Continue with current therapist: Jason Jones, MD

Continue with current psychiatrist: Karen Johnston, MD

Other: ________________________________________________________________

Signature below indicates that this Treatment Plan has been reviewed and approved:

Date: ________ Clinician: _____________________________ Title: _______________

Date: ________ Patient: ____________________________________

A copy of this treatment plan was: _____ given to the patient/family OR _____ declined by the patient/family.:

Date: ________ Clinician: _____________________________ Title: _______________

Electronically Signed

By: Elizabeth Lobao (MD)

On: 6/29/2012 1:35:59 PM

Note: Each member of the treatment team has the ability to e-sign this clinical record.