Progress Note Examples Mental Health

Progress Note Examples: Mental Health Documentation Done Right

Are you a mental health professional struggling to write effective and compliant progress notes? Do you find yourself spending too much time on documentation instead of focusing on your patients? Accurate and thorough progress notes are crucial for providing quality care, ensuring continuity of treatment, and protecting yourself legally. This comprehensive guide provides real-world progress note examples for mental health, covering various scenarios and illustrating best practices. We'll break down the essential components of a well-written progress note, offering clear examples to help you improve your documentation skills and streamline your workflow. By the end, you'll have a solid understanding of how to write progress notes that are both informative and compliant.

Understanding the Importance of Comprehensive Mental Health Progress Notes

Before diving into specific examples, let's underscore the critical role progress notes play in mental health care. These notes serve as a detailed record of a patient's treatment journey, including:

Treatment Planning & Progress: They track the patient's progress towards their treatment goals, documenting changes in symptoms, coping mechanisms, and overall functioning.
Legal Protection: Well-documented progress notes are essential for legal protection in case of malpractice claims or other legal disputes. They provide a clear and accurate account of the patient's care.
Communication & Collaboration: Notes facilitate seamless communication between healthcare providers, ensuring everyone is on the same page regarding the patient's treatment.
Insurance Reimbursement: Accurate documentation is necessary for insurance companies to understand the necessity and effectiveness of the provided treatment, thereby ensuring reimbursement.
Research & Quality Improvement: Aggregated data from progress notes can contribute to research and improve overall mental health care quality.

Progress Note Examples: Different Scenarios & Best Practices

Let's explore several examples of progress notes, illustrating how to document different clinical situations effectively. Remember, these are examples; always adapt them to your specific patient and clinical context.

Example 1: Initial Assessment for Depression

Patient: Jane Doe, 35-year-old female

Date: October 26, 2023

Presenting Problem: Patient presents with symptoms of major depressive disorder, including depressed mood, anhedonia, sleep disturbances, fatigue, and feelings of worthlessness for the past six months. Reports difficulty concentrating and decreased energy levels impacting her work performance. Denies suicidal ideation.

Mental Status Exam: Alert and oriented x3. Affect constricted. Speech slow and monotone. Thought process linear and logical. Insight and judgment fair.

Diagnosis: Major Depressive Disorder, Single Episode (DSM-5 296.20)

Treatment Plan: Initiated therapy sessions once a week. Prescribed sertraline 50mg daily. Patient will track mood and sleep patterns daily using a provided journal. Next appointment scheduled for November 2, 2023.

Example 2: Follow-up Session for Anxiety

Patient: John Smith, 28-year-old male

Date: October 27, 2023

Presenting Problem: Patient reports continued anxiety symptoms but notes a slight reduction in severity since the last session. Describes improved coping mechanisms and better sleep hygiene. Still experiences occasional panic attacks, but reports fewer occurrences.

Mental Status Exam: Alert and oriented x3. Affect anxious but less intense than previous sessions. Speech slightly pressured at times. Thought process linear. Insight and judgment good.

Treatment Plan: Continued weekly therapy sessions. Medication (alprazolam) remains unchanged. Patient will continue practicing relaxation techniques learned in previous sessions and will explore exposure therapy in upcoming sessions. Next appointment scheduled for November 3, 2023.

Example 3: Progress Note for a Patient Experiencing Psychosis

Patient: Sarah Jones, 40-year-old female

Date: October 28, 2023

Presenting Problem: Patient presents with ongoing auditory hallucinations, describing voices that are critical and derogatory. Reports increased paranoia and disorganized thought processes. Currently compliant with medication regimen.

Mental Status Exam: Alert but disoriented to time. Affect flat. Speech disorganized with loose associations. Thought process loose and tangential. Insight and judgment poor.

Treatment Plan: Continued medication management (antipsychotic medication). Focus on symptom stabilization and cognitive remediation therapy. Close monitoring for changes in mental status. Next appointment scheduled for November 1, 2023.

Key Components of Effective Progress Notes

Regardless of the specific scenario, every mental health progress note should include:

Identifying Information: Patient's name, date of birth, date of service.
Reason for Visit: Briefly state the purpose of the session.
Subjective Information: Patient's self-reported symptoms, feelings, and experiences (use direct quotes whenever possible).
Objective Information: Observable behaviors, mental status exam findings.
Assessment: Clinician's interpretation of the subjective and objective data, including diagnosis and treatment plan.
Plan: Outline of the treatment plan, including medication adjustments, therapy techniques, and follow-up appointments.

Ebook Outline: "Mastering Mental Health Progress Notes"

Introduction: The importance of accurate and effective progress note documentation in mental health.

Chapter 1: Essential Components of a Progress Note: A detailed breakdown of each section (identifying information, subjective, objective, assessment, plan).

Chapter 2: Progress Note Examples Across Different Diagnoses: Examples showcasing various mental health conditions (depression, anxiety, bipolar disorder, schizophrenia, etc.).

Chapter 3: Legal and Ethical Considerations: Addressing HIPAA compliance, documentation best practices, and avoiding common pitfalls.

Chapter 4: Improving Your Documentation Skills: Tips and strategies for efficient and effective progress note writing.

Conclusion: Recap of key takeaways and encouragement for continued learning and improvement.

Detailed Explanation of Ebook Chapters

Chapter 1: Essential Components of a Progress Note: This chapter will provide a step-by-step guide on structuring a progress note, explaining the purpose and content of each section. It will include examples of properly written sections and will offer guidance on how to use concise and professional language.

Chapter 2: Progress Note Examples Across Different Diagnoses: This chapter will feature a wider range of progress note examples, covering various diagnoses like anxiety disorders (generalized anxiety disorder, panic disorder, social anxiety disorder), mood disorders (bipolar disorder, persistent depressive disorder), personality disorders, and substance use disorders. Each example will highlight the specific aspects of the diagnosis that should be documented.

Chapter 3: Legal and Ethical Considerations: This chapter will delve into the legal and ethical responsibilities involved in maintaining patient records. It will cover HIPAA compliance, patient confidentiality, informed consent, and the potential legal consequences of inaccurate or incomplete documentation. It will also provide strategies to avoid malpractice claims.

Chapter 4: Improving Your Documentation Skills: This chapter will offer practical advice and strategies for improving the efficiency and effectiveness of progress note writing. It will include tips for using electronic health records (EHRs) effectively, time-management techniques, and strategies for avoiding writer's block.

FAQs

1. What is the difference between a progress note and a SOAP note? While similar, SOAP notes follow a specific structure (Subjective, Objective, Assessment, Plan), whereas progress notes are broader and may not always adhere to this strict format.

2. How often should I write progress notes? Frequency depends on the patient's needs and treatment plan, but generally, notes should be written after each session.

3. What if I make a mistake in a progress note? Never erase or delete; instead, draw a single line through the error, date and initial the correction.

4. How long should a progress note be? Length varies, but clarity and completeness are key; avoid unnecessary details.

5. Can I use abbreviations in my progress notes? Use only standard, widely accepted abbreviations to ensure clarity and compliance.

6. What should I do if a patient refuses treatment? Document the refusal, including the date, time, and the patient's reasons for refusal.

7. How do I handle sensitive information in progress notes? Follow all HIPAA regulations and use appropriate confidentiality measures.

8. What if I'm unsure about a diagnosis? Document your observations and uncertainties; consult with colleagues or supervisors if needed.

9. Where can I find more information on proper mental health documentation? Your state's licensing board and professional organizations offer resources and guidelines.

1. Mental Health Treatment Plans: A Comprehensive Guide: This article will provide detailed information on creating effective treatment plans, including goal setting and intervention strategies.

2. HIPAA Compliance for Mental Health Professionals: A guide to understanding and adhering to HIPAA regulations in mental health practice.

3. Common Mental Health Diagnoses Explained: This article will offer clear and concise explanations of common mental health diagnoses, including their symptoms and treatments.

4. Effective Communication Techniques in Mental Health: Tips and strategies for building strong therapeutic relationships with patients.

5. The Role of Medication in Mental Health Treatment: This article will discuss the various medications used to treat mental health conditions and their mechanisms of action.

6. Ethical Dilemmas in Mental Health Practice: An examination of common ethical challenges faced by mental health professionals and how to navigate them.

7. Mental Health First Aid: Recognizing and Responding to Mental Health Crises: This article explains how to offer support to someone experiencing a mental health crisis.

8. The Importance of Self-Care for Mental Health Professionals: This article emphasizes the importance of self-care and provides strategies for maintaining well-being.

9. Telehealth and Mental Health: Best Practices and Challenges: This article explores the use of telehealth in mental health, discussing its benefits and limitations.

progress note examples mental health: The Severe and Persistent Mental Illness Treatment Planner David J. Berghuis, Arthur E. Jongsma, Jr., Timothy J. Bruce, 2011-02-17 The flexible format of The Severe and Persistent Mental Illness Treatment Planner, 2nd Edition enables you to choose between evidence based and traditional “best practice” treatment approaches for your patients. Fully revised to meet your needs as a mental health professional working in today’s long-term care facilities, this time-saving resource contains over 1,000 rewritten treatment goals, objectives, and interventions, plus space for recording specific treatment plan options. This guide is organized around 31 behaviorally based issues, from employment problems and family conflicts, to financial needs and homelessness, to intimate relationship conflicts and social anxiety.
progress note examples mental health: STEPnotes(TM) Rhonda Sutton, 2013-08-28 This book is a way for counselors to conceptualize their therapy sessions with their clients. The STEPnotes structure aids in the therapeutic process, and provides a professional format for other administrative functions--Back cover
progress note examples mental health: The Counselor's Steps for Progress Notes Rhonda Sutton, 2015-06-21 Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.
progress note examples mental health: The Adult Psychotherapy Progress Notes Planner Arthur E. Jongsma, Jr., David J. Berghuis, 2014-01-27 Save hours of time-consuming paperwork with the bestselling treatment planning system The Adult Psychotherapy Progress Notes Planner, Fifth Edition contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 43 behaviorally based presenting problems, including depression, intimate relationship conflicts, chronic pain, anxiety, substance abuse, borderline personality, and more Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-5TM diagnostic categories in The Complete Adult Psychotherapy Treatment Planner, Fifth Edition Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA Identifies the latest evidence-based care treatments with treatment language following specific guidelines set by managed care and accrediting agencies
progress note examples mental health: The Well-Managed Mental Health Practice Donald E. Wiger, 2007-10-05 The step-by-step guide to building and managing a profitable and successful practice or clinic Beyond your training as a therapist, the skills required to create and build a practice and to supervise others are typically not taught as part of your clinical training. There are myriad decisions you must make, including financial, organizational, and marketing decisions, that will determine the success and profitability of your practice, group practice, or clinic. The Well-Managed Mental Health Practice draws from author Donald Wiger's vast experience as owner and manager of both small and large mental health practices and clinics. This helpful resource provides sound business practices, immediately useful insights into the accrediting process, and other critical information you will need to avoid legal trouble, ensure payment from individuals and third party payors, and create a thriving practice. Designed for practices or clinics of any size and at any stage of development--from start-up through mature business--this easy-to-follow book looks at all the issues involved with starting and running a mental health practice and offers: * Practical advice on how to increase business, develop your professional reputation, and set priorities, as well as helpful insights on customer service, employee relations, time management, and coping with stress * Indispensable tools for developing business and management skills to ensure smooth operation and maximum profitability * Useful tips for handling problems encountered by clinic directors and clinic decision-makers * Numerous sample forms and procedural documents A vital reference for a wide range of mental health professionals, The Well-Managed Mental Health Practice is an important guide that will equip you with the skills necessary to develop a financially successful practice that survives and thrives.
progress note examples mental health: The Clinical Documentation Sourcebook Donald E. Wiger, 2010-02-02 All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
progress note examples mental health: Note Designer Patricia C Baldwin, 2016-03-23 This book provides step-by-step guidelines, tips, and instruction on how to create and write psychotherapy treatment notes. Information and guidance are provided on how to write a treatment intake report, treatment progress notes, and termination summary. A number of sample notes, reports and templates are provided. The book also includes hundreds of representative statements for therapists to use in the design of their own psychotherapy progress notes. A valuable resource for experienced mental health professionals and trainees alike, from the creator of Note Designer therapy note-writing software. A time-saving reference to capture the essence and the methods of professional note writing for psychotherapists. Easy to apply and great to keep close-by when writing reports and progress notes. --Alexandre Smith-Peter, Psy.D. candidate
progress note examples mental health: The OTA's Guide to Writing SOAP Notes Sherry Borcherding, Marie J. Morreale, 2007 Written specifically for occupational therapy assistants, The OTA's Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. This valuable text contains the step-by-step instruction needed to learn the documentation required for reimbursement in occupational therapy. With the current changes in healthcare, proper documentation of client care is essential to meeting legal and ethical standards for reimbursement of services. Written in an easy-to-read format, this new edition by Sherry Borcherding and Marie J. Morreale will continue to aid occupational therapy assistants in learning to write SOAP notes that will be reimbursable under Medicare Part B and managed care for different areas of clinical practice. New Features in the Second Edition: - Incorporated throughout the text is the Occupational Therapy Practice Framework, along with updated AOTA documents - More examples of pediatrics, hand therapy, and mental health - Updated and additional worksheets - Review of grammar/documentation mistakes - Worksheets for deciphering physician orders, as well as expanded worksheets for medical abbreviations - Updated information on billing codes, HIPAA, management of health information, medical records, and electronic documentation - Expanded information on the OT process for the OTA to fully understand documentation and the OTA's role in all stages of treatment, including referral, evaluation, intervention plan, and discharge - Documentation of physical agent modalities With reorganized and shorter chapters, The OTA's Guide to Writing SOAP Notes, Second Edition is the essential text to providing instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional edition offers both the necessary instruction and multiple opportunities to practice, as skills are built on each other in a logical manner. Templates are provided for beginning students to use in formatting SOAP notes, and the task of documentation is broken down into small units to make learning easier. A detachable summary sheet is included that can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Updated information, expanded discussions, and reorganized learning tools make The OTA's Guide to Writing SOAP Notes, Second Edition a must-have for all occupational therapy assistant students! This text is the essential resource needed to master professional documentation skills in today's healthcare environment.
progress note examples mental health: Stepped Care 2.0: A Paradigm Shift in Mental Health Peter Cornish, 2020-06-13 This book is a primer on Stepped Care 2.0. It is the first book in a series of three. This primer addresses the increased demand for mental health care by supporting stakeholders (help-seekers, providers, and policy-makers) to collaborate in enhancing care outcomes through work that is both more meaningful and sustainable. Our current mental health system is organized to offer highly intensive psychiatric and psychological care. While undoubtedly effective, demand far exceeds the supply for such specialized programming. Many people seeking to improve their mental health do not need psychiatric medication or sophisticated psychotherapy. A typical help seeker needs basic support. For knee pain, a nurse or physician might first recommend icing and resting the knee, working to achieve a healthy weight, and introducing low impact exercise before considering specialist care. Unfortunately, there is no parallel continuum of care for mental health and wellness. As a result, a person seeking the most basic support must line up and wait for the specialist along with those who may have very severe and/or complex needs. Why are there no lower intensity options? One reason is fear and stigma. A thorough assessment by a specialist is considered best practice. After all, what if we miss signs of suicide or potential harm to others? A reasonable question on the surface; however, the premise is flawed. First, the risk of suicide, or threat to others, for those already seeking care, is low. Second, our technical capacity to predict on these threats is virtually nil. Finally, assessment in our current culture of fear tends to focus more on the identification of deficits (as opposed to functional capacities), leading to over-prescription of expensive remedies and lost opportunities for autonomy and self-management. Despite little evidence linking assessment to treatment outcomes, and no evidence supporting our capacity to detect risk for harm, we persist with lengthy intake assessments and automatic specialist referrals that delay care. Before providers and policy makers can feel comfortable letting go of risk assessment, however, they need to understand the forces underlying the risk paradigm that dominates our society and restricts creative solutions for supporting those in need.
progress note examples mental health: The Early Childhood Education Intervention Treatment Planner David J. Berghuis, Julie A. Winkelstern, 2006-04-20 The Early Childhood Education Intervention Treatment Planner provides all the elements necessaryto quickly and easily develop formal education treatment plans that take the educational professional a step further past the writing of goals for Individualized Education Plans (IEPs) as well as mental health treatment plans. The educational treatment plan process assists the professional in identifying interventions and communicating to others the specific method, means, format, and/or creative experience by which the student will be assisted in attaining IEP goals. Critical tool for treating the most common problems encountered in treating children ages 3-6 Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized educational treatment plans Organized around 27 main presenting problems, including autism, cultural and language issues, depression, eating and elimination concerns, cognitive and neurological impairment, oppositional behavior, school entry readiness, and others Over 1,000 well-crafted, clear statements describe the behavioral manifestations of each relational problem, long-term goals, short-term objectives, and educational interchange Easy-to-use reference format helps locate educational treatment plan components by disability Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies (including HCFA, JCAHO, and NCQA)
progress note examples mental health: Case Conceptualization Len Sperry, Jon Sperry, 2020-05-27 Integrating recent research and developments in the field, this revised second edition introduces an easy-to-master strategy for developing and writing culturally sensitive case conceptualizations and treatment plans. Concrete guidelines and updated case material are provided for developing conceptualizations for the five most common therapy models: Cognitive-Behavioral Therapy (CBT), Psychodynamic, Biopsychosocial, Adlerian, and Acceptance and Commitment Therapy. The chapters also include specific exercises and activities for mastering case conceptualization and related competencies and skills. Also new to this edition is a chapter on couple and family case conceptualizations, and an emphasis throughout on trauma. Practitioners, as well as graduate students in counseling and in clinical psychology, will gain the essential skills and knowledge they need to master case conceptualizations.
progress note examples mental health: Mental Health and Psychiatric Nursing Janet L. Davies, Ellen Hastings Janosik, 1991
progress note examples mental health: The Complete Adult Psychotherapy Treatment Planner David J. Berghuis, L. Mark Peterson, 2012-07-03 The Complete Adult Psychotherapy Treatment Planner, Fourth Edition provides all the elements necessary to quickly and easily develop formal treatment plans that satisfy the demands of HMOs, managed care companies, third-party payors, and state and federal agencies. New edition features: Empirically supported, evidence-based treatment interventions Organized around 43 main presenting problems, including anger management, chemical dependence, depression, financial stress, low self-esteem, and Obsessive-Compulsive Disorder Over 1,000 prewritten treatment goals, objectives, and interventions - plus space to record your own treatment plan options Easy-to-use reference format helps locate treatment plan components by behavioral problem Designed to correspond with the The Adult Psychotherapy Progress Notes Planner, Third Edition and the Adult Psychotherapy Homework Planner, Second Edition Includes a sample treatment plan that conforms to the requirements of most third-party payors and accrediting agencies (including CARF, JCAHO, and NCQA).
progress note examples mental health: Clinician's Thesaurus Edward L. Zuckerman, 2019-03-20 Hundreds of thousands of students and early-career professionals have relied on this authoritative report-writing tool, now updated for DSM-5/ICD-10-CM and newer types of evaluations. In a convenient 8 x 10.5 format, the book covers nearly all areas of concern addressed in intakes, evaluations, treatment plans, progress notes, and closing summaries. The user seeking the right wording for a clinical document can skim and select from thousands of technical terms, behavioral descriptors, and standard statements. Also provided are interview questions for almost every symptomatic behavior, a huge collection of mental status questions, a reproducible Mental Status Evaluation summary form, and links to hundreds of internet resources. The companion website offers all the URLs from the book, the reproducible forms, and a handy reference on current psychiatric medications. New to This Edition *A list of all psychiatric ICD-10 diagnoses (all of the codes in DSM-5, plus many more), including Z codes essential to a comprehensive biopsychosocial evaluation. *Sample evaluation report keyed to the book's chapters. *Sections on additional clinical issues: intimate partner violence, gender identity, human trafficking, recovery-oriented language, and more. *Many more Internet links, including a wide variety of screening and assessment tools. See also The Paper Office for the Digital Age, Fifth Edition, by Edward L. Zuckerman and Keely Kolmes, which provides the essential record-keeping and risk-reduction tools that every psychotherapy practice needs.
progress note examples mental health: The Mental Health Desk Reference Elizabeth Reynolds Welfel, R. Elliott Ingersoll, 2004-01-05 A practical, easy-to-use, and comprehensive reference for mental health professionals The Mental Health Desk Reference is the ultimate guide to effective and responsible mental health practice. It provides authoritative, concise, and up-to-date information from more than seventy experts regarding diagnosis, treatment, and ethics of practice. Each entry summarizes key constructs and terminology associated with the topic, major findings from research, and specific recommendations on theory and practice. Important topics covered include: * Adjustment disorders and life stress * Diagnosis and treatment of adults * Diagnosis and treatment of children * Crisis intervention * Diverse populations * Group and family interventions * Practice management * Professional issues * Ethical and legal issues * Professional resources These detailed, readable entries-based on the most extensive and reliable research available-form a comprehensive, straightforward, and quick-reference resource applicable to practitioners across every field in mental health. The Mental Health Desk Reference is the single resource no mental health professional can afford to be without.
progress note examples mental health: FAMILY THERAPY TECHNIQUES Salvador MINUCHIN, H. Charles Fishman, 2009-06-30 A master of family therapy, Salvador Minuchin, traces for the first time the minute operations of day-to-day practice. Dr. Minuchin has achieved renown for his theoretical breakthroughs and his success at treatment. Now he explains in close detail those precise and difficult maneuvers that constitute his art. The book thus codifies the method of one of the country's most successful practitioners.
progress note examples mental health: Basic Concepts of Psychiatric-mental Health Nursing Louise Rebraca Shives, 2007 This seventh edition includes new chapters and maintains popular features from previous editions such as self awareness prompts while adding research boxes and student worksheets at the end of each chapter.
progress note examples mental health: Writing Patient/Client Notes Ginge Kettenbach, Sarah Lynn Schlomer, Jill Fitzgerald, 2016-05-11 Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.
progress note examples mental health: The Psychotherapy Documentation Primer Donald E. Wiger, 2012-06-25 Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Third Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. The new edition features: Revised examples of a wider range of psychological concerns New chapters on documentation ethics and the art and science of psychological assessment and psychotherapy Study questions and answers at the end of each chapter Greatly expanded, The Psychotherapy Documentation Primer, Third Edition continues to be the benchmark record-keeping reference for working professionals, reflecting the latest in documentation and reporting requirements.
progress note examples mental health: Collaborative Problem Solving Alisha R. Pollastri, J. Stuart Ablon, Michael J.G. Hone, 2019-06-06 This book is the first to systematically describe the key components necessary to ensure successful implementation of Collaborative Problem Solving (CPS) across mental health settings and non-mental health settings that require behavioral management. This resource is designed by the leading experts in CPS and is focused on the clinical and implementation strategies that have proved most successful within various private and institutional agencies. The book begins by defining the approach before delving into the neurobiological components that are key to understanding this concept. Next, the book covers the best practices for implementation and evaluating outcomes, both in the long and short term. The book concludes with a summary of the concept and recommendations for additional resources, making it an excellent concise guide to this cutting edge approach. Collaborative Problem Solving is an excellent resource for psychiatrists, psychologists, social workers, and all medical professionals working to manage troubling behaviors. The text is also valuable for readers interested in public health, education, improved law enforcement strategies, and all stakeholders seeking to implement this approach within their program, organization, and/or system of care.
progress note examples mental health: The SAFER-R Model George Everly, Jr., 2017-04 Psychological Crisis Intervention: The SAFER-R Model is designed to provide the reader with a simple set of guidelines for the provision of psychological first aid (PFA). The model of psychological first aid (PFA) for individuals presented in this volume is the SAFER-R model developed by the authors. Arguably it is the most widely used tactical model of crisis intervention in the world with roughly 1 million individuals trained in its operational and derivative guidelines. This model of PFA is not a therapy model nor a substitute for therapy. Rather it is designed to help crisis interventionists stabile and mitigate acute crisis reactions in individuals, as opposed to groups. Guidelines for triage and referrals are also provided. Before plunging into the step-by-step guidelines, a brief history and terminological framework is provided. Lastly, recommendations for addressing specific psychological challenges (suicidal ideation, resistance to seeking professional psychological support, and depression) are provided.
progress note examples mental health: The Child Psychotherapy Progress Notes Planner Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, David J. Berghuis, 2004-05-21 The Child Psychotherapy Progress Notes Planner, Second Editioncontains complete prewritten session and patient presentationdescriptions for each behavioral problem in The Child PsychotherapyTreatment Planner, Third Edition. The prewritten progress notes canbe easily and quickly adapted to fit a particular client need ortreatment situation. * Saves you hours of time-consuming paperwork, yet offers thefreedom to develop customized progress notes * Organized around 33 main presenting problems that range fromblended family problems and children of divorce to ADHD, attachmentdisorder, academic problems, and speech and languagedisorders * Features over 1,000 prewritten progress notes (summarizingpatient presentation, themes of session, and treatmentdelivered) * Provides an array of treatment approaches that correspond withthe behavioral problems and DSM-IV-TR(TM) diagnostic categories inThe Child Psychotherapy Treatment Planner, Third Edition * Offers sample progress notes that conform to the requirements ofmost third-party payors and accrediting agencies, including theJCAHO and the NCQA
progress note examples mental health: Clinical Supervision and Professional Development of the Substance Abuse Counselor United States. Department of Health and Human Services, 2009 Clinical supervision (CS) is emerging as the crucible in which counselors acquire knowledge and skills for the substance abuse (SA) treatment profession, providing a bridge between the classroom and the clinic. Supervision is necessary in the SA treatment field to improve client care, develop the professionalism of clinical personnel, and maintain ethical standards. Contents of this report: (1) CS and Prof¿l. Develop. of the SA Counselor: Basic info. about CS in the SA treatment field; Presents the ¿how to¿ of CS.; (2) An Implementation Guide for Admin.; Will help admin. understand the benefits and rationale behind providing CS for their program¿s SA counselors. Provides tools for making the tasks assoc. with implementing a CS system easier. Illustrations.
progress note examples mental health: Mental Health Atlas 2017 World Health Organization, 2018-08-09 Collects together data compiled from 177 World Health Organization Member States/Countries on mental health care. Coverage includes policies, plans and laws for mental health, human and financial resources available, what types of facilities providing care, and mental health programmes for prevention and promotion.
progress note examples mental health: The OTA’s Guide to Documentation Marie Morreale, 2024-06-01 The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions. New in the Fifth Edition: Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents Updated information to meet Medicare Part B and other third-party payer requirements Revised clinical terminology on par with current trends Added examples from emerging practice areas Expanded tables along with new worksheets and learning activities Included with the text are online supplemental materials for faculty use in the classroom, this includes: access to supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.
progress note examples mental health: Common Mental Health Disorders National Collaborating Centre for Mental Health (Great Britain), 2011 Bringing together treatment and referral advice from existing guidelines, this text aims to improve access to services and recognition of common mental health disorders in adults and provide advice on the principles that need to be adopted to develop appropriate referral and local care pathways.
progress note examples mental health: Laziness Does Not Exist Devon Price, 2021-01-05 From social psychologist Dr. Devon Price, a conversational, stirring call to “a better, more human way to live” (Cal Newport, New York Times bestselling author) that examines the “laziness lie”—which falsely tells us we are not working or learning hard enough. Extra-curricular activities. Honors classes. 60-hour work weeks. Side hustles. Like many Americans, Dr. Devon Price believed that productivity was the best way to measure self-worth. Price was an overachiever from the start, graduating from both college and graduate school early, but that success came at a cost. After Price was diagnosed with a severe case of anemia and heart complications from overexertion, they were forced to examine the darker side of all this productivity. Laziness Does Not Exist explores the psychological underpinnings of the “laziness lie,” including its origins from the Puritans and how it has continued to proliferate as digital work tools have blurred the boundaries between work and life. Using in-depth research, Price explains that people today do far more work than nearly any other humans in history yet most of us often still feel we are not doing enough. Filled with practical and accessible advice for overcoming society’s pressure to do more, and featuring interviews with researchers, consultants, and experiences from real people drowning in too much work, Laziness Does Not Exist “is the book we all need right now” (Caroline Dooner, author of The F*ck It Diet).
progress note examples mental health: Writing S.O.A.P. Notes Ginge Kettenbach, 1990 -- Chapter on the development and use of forms and documentation-- Coverage of computerized documentation-- Thorough updating, including a discussion of the managed care environment and Medicare-- Additional exercises and examples-- Perforated worksheets-- Basic note-writing rules, including the POMR method, are reviewed-- Examples provided of both correct and incorrect note writing
progress note examples mental health: Personal Recovery and Mental Illness Mike Slade, 2009-05-28 Focuses on a shift away from traditional clinical preoccupations towards new priorities of supporting the patient.
progress note examples mental health: What is Narrative Therapy? Alice Morgan, 2000 This best-selling book is an easy-to-read introduction to the ideas and practices of narrative therapy. It uses accessible language, has a concise structure and includes a wide range of practical examples. What Is Narrative Practice? covers a broad spectrum of narrative practices including externalisation, re-membering, therapeutic letter writing, rituals, leagues, reflecting teams and much more. If you are a therapist, health worker or community worker who is interesting in applying narrative ideas in your own work context, this book was written with you in mind.
progress note examples mental health: The Family Therapy Progress Notes Planner David J. Berghuis, Arthur E. Jongsma, Jr., 2004-07-22 The Family Therapy Progress Notes Planner contains completeprewritten session and patient presentation descriptions for eachbehavioral problem in The Family Therapy Treatment Planner.The prewritten progress notes can be easily and quickly adapted tofit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers thefreedom to develop customized progress notes Organized around 38 main presenting problems that range fromfamily business conflicts and inheritance disputes to alcoholabuse, physical/verbal/psychological abuse, and religious/spiritualconflicts Features over 1,000 prewritten progress notes (summarizingpatient presentation, themes of session, and treatmentdelivered) Provides an array of treatment approaches that correspond withthe behavioral problems and DSM-IV-TR(TM) diagnostic categories inThe Family Therapy Treatment Planner Offers sample progress notes that conform to the requirementsof most third-party payors and accrediting agencies, including theJCAHO and the NCQA
progress note examples mental health: Practicum and Internship Experiences in Counseling Bradley T. Erford, 2023-03-24 This ready-to-use resource provides the practical information and hands-on skills interns and practicum students need to successfully complete their clinical experiences and join the counseling profession with confidence. Designed to accompany students as they advance through practicum and internship, Practicum and Internship Experiences in Counseling helps bridge the gap from theory to practice. It covers the day-to-day elements of practice in agencies and schools that are often missing from the theory-based courses. Chapters are packed with case examples, activities, voices from the field, and self-assessments, including tools for assessing and addressing ethnocentrism, intersectionality, and bias in counseling practice. This resource orients clinical students to the field, while providing them with the day-to-day skills they need to thrive. Special focus on: Expectations and how to get the most out of the supervision process Assessment and intervention with clients in danger and crisis Wellness and developing healthy work and personal habits to carry through one’s entire career. Readers see clearly how to: Apply the laws and ethics in everyday clinical practice Work with special issues (neuropsych and psychopharmacology) and populations Market and position oneself in the job market, with an eye toward growing/marketing a counseling practice after graduation Included in each chapter: Several self-assessment activities encouraging self-reflection and self-assessment on the concepts of the chapter Voices from the field features providing firsthand, in-the-trenches perspectives from counselors who have been there and done that. Realistic case examples challenging readers to apply knowledge and skills to realistic cases they are likely to encounter in the field Included are separate chapters on: Relationship building Goal setting Record keeping The integration of theory into practice
progress note examples mental health: Introduction to Clinical Mental Health Counseling Joshua C. Watson, Michael K. Schmit, 2019-01-23 Introduction to Clinical Mental Health Counseling presents a broad overview of the field of clinical mental health and provides students with the knowledge and skills to successfully put theory into practice in real-world settings. Drawing from their experience as clinicians, authors Joshua C. Watson and Michael K. Schmit cover the foundations of clinical mental health counseling along with current issues, trends, and population-specific considerations. The text introduces students to emerging paradigms in the field such as mindfulness, behavioral medicine, neuroscience, recovery-oriented care, provider care, person-centered treatment planning, and holistic wellness, while emphasizing the importance of selecting evidence-based practices appropriate for specific clients, issues, and settings. Aligned with 2016 CACREP Standards and offering practical activities and case examples, the text will prepare future counselors for the realities of clinical practice.
progress note examples mental health: The Severe and Persistent Mental Illness Progress Notes Planner David J. Berghuis, Arthur E. Jongsma, Jr., 2002-12-09 This timesaving resource features: Progress notes components for 25 behaviorally based presenting problems that correlate with The Severe and Persistent Mental Illness Treatment Planner Over 1,000 prewritten progress notes describing client presentation and interventions implemented Prewritten progress notes that can be quickly adapted to fit a particular client need or treatment situation The Severe and Persistent Mental Illness Progress Notes Planner contains complete prewritten session and patient presentation descriptions for each behavioral problem in The Severe and Persistent Mental Illness Treatment Planner. The prewritten progress notes can be easily and quickly adapted to fit a particular client need or treatment situation. Saves you hours of time-consuming paperwork, yet offers the freedom to develop customized progress notes Organized around 25 main presenting problems that range from antisocial behavior and eating disorders to anxiety, substance abuse, gambling, and others Features over 1,000 prewritten progress notes (summarizing patient presentation, themes of session, and treatment delivered) Provides an array of treatment approaches that correspond with the behavioral problems and DSM-IV™ diagnostic categories in The Severe and Persistent Mental Illness Treatment Planner Offers sample progress notes that conform to the requirements of most third-party payers and accrediting agencies, including the JCAHO and the NCQA
progress note examples mental health: Clinician's Guide to Psychological Assessment and Testing John M. Spores, 2012-09-18 This nuts-and-bolts guide to conducting efficient and accurate psychological testing in clinical settings provides mental health professionals with experienced guidance in the entire process. It features a complete set of printed and electronic forms and templates for all aspects of assessment and testing, from the initial referral to the final report. It presents a standardized process of assessment, testing, interpretation, report-writing, and presenting feedback. Integral to the book is a review of psychological tests in seven key categories that most effectively address differential diagnostic dilemmas that clinicians are likely to encounter in practice. Numerous case examples illustrate the process in action.
progress note examples mental health: Improving the Quality of Health Care for Mental and Substance-Use Conditions Institute of Medicine, Board on Health Care Services, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, 2006-03-29 Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€use conditions will benefit from this guide to achieving better care.
progress note examples mental health: Partnering for Recovery in Mental Health Janis Tondora, Rebecca Miller, Mike Slade, Larry Davidson, 2014-05-19 Partnering for Recovery in Mental Health is a practical guide for conducting person and family-centered recovery planning with individuals with serious mental illnesses and their families. It is derived from the authors’ extensive experience in articulating and implementing recovery-oriented practice and has been tested with roughly 3,000 providers who work in the field as well as with numerous post-graduate trainees in psychology, social work, nursing, and psychiatric rehabilitation. It has consistently received highly favorable evaluations from health care professionals as well as people in recovery from mental illness. This guide represents a new clinical approach to the planning and delivery of mental health care. It emerges from the mental health recovery movement, and has been developed in the process of the efforts to transform systems of care at the local, regional, and national levels to a recovery orientation. It will be an extremely useful tool for planning care within the context of current health care reform efforts and increasingly useful in the future, as systems of care become more person-centered. Consistent with other patient-centered care planning approaches, this book adapts this process specifically to meet the needs of persons with serious mental illnesses and their families. Partnering for Recovery in Mental Health is an invaluable guide for any person involved directly or indirectly in the provision, monitoring, evaluation, or use of community-based mental health care.
progress note examples mental health: Cognitive Processing Therapy for PTSD Patricia A. Resick, Candice M. Monson, Kathleen M. Chard, 2016-12-26 The culmination of more than 25 years of clinical work and research, this is the authoritative presentation of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD). Written by the treatment's developers, the book includes session-by-session guidelines for implementation, complete with extensive sample dialogues and 40 reproducible client handouts. It explains the theoretical and empirical underpinnings of CPT and discusses how to adapt the approach for specific populations, such as combat veterans, sexual assault survivors, and culturally diverse clients. The large-size format facilitates photocopying and day-to-day use. Purchasers also get access to a Web page where they can download and print the reproducible materials. CPT is endorsed by the U.S. Departments of Veterans Affairs and Defense, the International Society of Traumatic Stress Studies, and the U.K. National Institute for Health and Care Excellence (NICE) as a best practice for the treatment of PTSD.
progress note examples mental health: Adolescent Psychotherapy Homework Planner Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, Timothy J. Bruce, 2024-01-04 Evidence-based and effective clinical homework for adolescent clients and their caregivers In the newly updated sixth edition of The Adolescent Psychotherapy Homework Planner, a team of distinguished practitioners delivers a time-saving and hands-on practice tool designed to offer clients valuable homework assignments that will further their treatment goals for a wide variety of presenting problems. The Homework Planner addresses common and less-common disorders—including anxiety, depression, substance use, eating, and panic—allowing the client to work between sessions on issues that are the focus of therapy. This book provides evidence-based homework assignments that track the psychotherapeutic interventions suggested by the fifth edition of The Adolescent Psychotherapy Treatment Planner. They are easily photocopied, and a digital version is provided online for the therapist who would prefer to access them with a word processor. The Homework Planner also offers: Cross-referenced lists of suggested presenting problems for which each assignment may be appropriate (beyond its primary designation) Several brand-new assignments, as well as adapted assignments that have been shortened or modified to make them more adolescent-client-friendly Homework assignments for the parents of adolescents in treatment, assignments for the adolescents themselves, and assignments for parents and adolescents to complete together An essential and practical tool for therapists and practitioners treating adolescents, The Adolescent Psychotherapy Homework Planner, Sixth Edition will benefit social workers, psychologists, psychiatrists, and other clinicians seeking efficient and effective homework tools for their clients.
progress note examples mental health: Treatment Plans and Interventions for Depression and Anxiety Disorders Robert L. Leahy, Stephen J. Holland, Lata K. McGinn, 2011-10-26 _This widely used book is packed with indispensable tools for treating the most common clinical problems encountered in outpatient mental health practice. Chapters provide basic information on depression and the six major anxiety disorders; step-by-stepinstructions for evidence-based assessment and intervention; illustrative case examples; and practical guidance for writing reports and dealing with third-party payers. In a convenient large-size format, the book features 125 reproducible client handouts, homework sheets, and therapist forms for assessment and record keeping. The included CD-ROM enables clinicians to rapidly generate individualized treatment plans, print extra copies of the forms, and find information on frequently prescribed medications._New to This Edition*The latest research on each disorder and its treatment.*Innovative techniques that draw on cognitive, behavioral, mindfulness, and acceptance-based approaches.*Two chapters offering expanded descriptions of basic behavioral and cognitive techniques.*47 of the 125 reproducibles are entirely new. __--Provided by publisher.

Progress Note Examples Mental Health