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Clinician Progress Note Taking

Clinician Treatment Tools

Clinical Progress Notes

Clinical Mental Health Counselors are best serving their clients by keeping track of their clients' progress after every scheduled clinical session. What follows is an outline for such progress notes. 

 

Client’s Name:

Date:

Client’s Principal Diagnosis:

  1. Treatment Goal and Objective to be addressed in this session:
  2. Results of Client’s Homework from last session:
  3. Clinical intervention used in current session:
  4. Client’s response to intervention used:
  5. Resistance to change/Barriers to goal attainment:
  6. Progress towards goals and objectives witnessed in session:
  7. Homework given client at end of session:
  8. Plan for next session’s interventions:

 

By using the above outline clinicians will be able to be more consistent and on target in working with their clients since they will always be harkening back to their original clinical assessment and treatment plans, goals, objectives and intended interventions.  Clinical Mental Health Counselors who consistently record the progress or lack of progress of their clients in this way are being accountable not only to their clients but also to their agencies and/or third party payors involved in the providing of mental health services to their clients. 
 
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Clinical Progress Notes Based On Initial Assessment & Treatment Plan
How to Use Evidenced Based Practices to Improve 
Initial Assessment & Treatment Planning

Dr. Donald Meichenbaum a founder of the CBT movement has made available free to all practictioners his summary of steps which practictioners can take to improve their intake interviews, case conceptualizations and treatment planning. These articles can be obtained on www.melissainstitute.org. His emphasis is on a thorough interview to help in case conceptualizaation and treatment planning. Please read the following two articles to understand more his perspective.
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Core tasks of psychotherapy/counseling: What "expert" therapists do
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Psychocultural Assessment & Intervention: The need for a case conceptualization model

Case Study Report Format

Mental Health Counselors are called upon to provide a complete Case Study Report concerning clients whom they have seen while in training for Practicum and Internships. These Case Studies ought to include not only the above Initial Assessment Report format but also include the following:

 

Course of Treatment: 

Give a narrative description of the course of treatment with the client and be sure to describe:
  1. How the client responded to the interventions?
  2. What resistance was present during the course of treatment with this client?
  3. How open and free was the client to participating in the treatment plan?
  4. What changes if any did you need to make in your treatment plan for this client?
  5. Was there a change in your tentative diagnosis at the end of treatment with this client?
  6. What would you have done differently with this client knowing what you know today?
  7. What did you learn about yourself as a counselor from working with this client?

 

Impact of Treatment Plan:

  1. Results for Long Term Goal #1
  2. Results for Long Term Goal #2
  3. Results for Long Term Goal #3
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Template for Mental Health Counseling Case Study Presentation

TIPS For Mental Health Counseling Client’s Progress Notes

 

Mental Status Definitions

Affect: current display of emotional state

Euthymic: normal, absence of depressed or elevated emotional experience

Irritable: easily annoyed, impatient

Constricted: mild reduction of intensity of emotional experience

Blunted: significant reduction of intensity of emotional expression

Flat: absence of emotional experience

Inappropriate: emotional expression does not match content of speech, thought

Labile: abnormal sudden rapid shifts of emotional experience

Anhedonia: lack of experience of pleasure with normally pleasurable activity

Dysphoria: unhappy, depressed, anxious, irritable

Dysthymic: depressed, not content

Euphoria: extreme happiness

Euthymic: reasonably content

Mood: global, diffuse emotional state in general

Recommendations for Behavioral Objectives

Here are some suggestions to help you in writing short-term, measurable and concrete behavioral objectives. Remember: the “goal” is the long-term, at-the-end-of-treatment statement, and the behavioral objectives are the shorter measures to prove that treatment is progressing towards those goals. Behavioral objectives can and should change over the course of treatment; as the patient achieves an objective, it is appropriate to negotiate a new set of behavioral changes. The blanks in the statements that follow should be a number of episodes, thus giving a monitoring graph of the patient’s progress over time. Some ideas (adapted in part from the Jongsma Treatment Planner series):

 

Depression: Client will:

Identify ___ triggers for the depressed mood

Verbalize understanding between [underlying losses, etc] & depressed mood

Eat ____ % of meals by session # ___ (if anorexia is part of the depression)

Sleep ____ hrs. & report restorative sleep (if insomnia is part of the depression)

Verbalize __ pleasurable past activities (if anhedonia is present)

Comply w/ antidepressant medication treatment plan

Replace negative and self-defeating talk with ___ verbalizations of realistic and positive cognitive messages

Will make __ positive statements regarding self/ability to cope w/ stressors

 

Anxiety: Client will:

Identify ____ stressors which exacerbate anxiety reactions

State ____ positive coping strategies in next session

Identify ___ irrational aspects of worrisome thoughts

Develop and utilize ___ relaxation/diversion activities to decrease anxiety

Learn ___ cognitive-behavioral strategies to reduce/eliminate anxiety

Make __ positive statements regarding ability to manage stressors

 

Suicidal Ideation (SI): Client will:

Identify factors that preceded the suicidal ideation

Report no longer feeling the impulse to suicide

Report decrease in frequency and intensity of SI to less than ___ times per week

Establish a consistent eating and sleeping pattern by session #__ (if problematic)

Verbalize feelings, with appropriate affect, that underlie SI

Identify ___ positive reasons to live

Report SI to _______

Contract for safety/sign plan for safety

Take medications as prescribed


Recommendations for Details on Clinical Interventions

The “Interventions” must be indicative of the clinical depth of the interventions identified. In other words, “what did this licensed mental health counselor do to target the client’s signs and symptoms that only this practitioner can do?” Therefore, statements such as “provided active listening and empathy,” or “provided support” are not adequate so an Auditor or Reviewer would have grounds for denying such description of the intervention.

Examples of Good Documentation of Cognitive Behavioral Treatment Interventions

Cognitive restructuring used to defuse helplessness and negative forecasting associated with catastrophizing about symptoms.

 

Taught and reviewed recording cognitions and changing attitudes and self-statements to promote normalize activity at both home and work.

 

CBT/cognitions examination used to encourage emotional expression and helped client develop ways of containing affect.

 

CBT used to restructure thoughts with emphasis on helping client to manage emotions, including fear and sadness that are realistic and understandable in context of diagnosis and degree of functional losses.

 

Used CBT to help client understand personal meaning of issues being confronted.

 

Engaged client in evaluating thoughts in terms of their usefulness and their basis in reality.

 

Client learning to identify and challenge beliefs that represent distortions of reality and that are destructive to client’s well-being.

 

CBT interventions used to focus on reducing the stress-producing cognitive patterns that give rise to muscle tension that increases client’s pain response.

 

Use of cognitive approaches included monitoring negative thoughts, connecting affect and cognitions, and substituting positive interpretations for negative thoughts.

CBT Key Terms to Improve Intervention Documentation

Cognitive Errors: faulty assumptions and misconceptions that may be caused by past experiences but are not based on current reality/logic. Mistakes in thinking that can lead people to be sad, lonely, angry, depressed, etc.

 

Thought Stopping: Process of substituting negative/maladaptive thoughts or images with positive/adaptive ones; management of cues that trigger obsessions, impulsivity, or compulsions; use of mental energy in healthy way; stress/distress reduction technique.

 

Rational Restructuring: (Lazarus) Helping clients to label situations more realistically via rational analysis, confrontation, questioning, “modifying internal sentences,” modifying “self-talk.” Example: Ellis’ RET (Rational-Emotive Therapy) in which people learn to confront their own illogical thinking.

 

Behavioral Coping Strategies: Specific efforts that can be employed to master, tolerate, reduce, or minimize stressful and painful events. Active coping strategies are better to deal with distress thanavoidant coping strategies, which can be a risk factor or marker for adverse responses to distress. Examples: exercise, journaling/charting, volunteering, relaxation, talk therapy, etc.

 

Re-Frame: Inviting client to see a new perspective. Modifies or restructures a client’s perception or view of a problem or behavior; Changing the way a client “encodes” issue; restructuring what a client perceives and shifting focus on to the real issue or a more productive topic. Challenging the “meaning” given to a problem by helping client “find” acceptable alternative understandings.

 

Self-Efficacy: (Bandura) A client’s expectations of personal effectiveness; personal beliefs about one’s own abilities or performance potential.

 

Modeling: Observational learning to alter behavior patterns; highly useful in treating anxiety/phobic symptoms; types include: imitation, observation, participant modeling, guided participation and covert modeling (imagining a model engaged in desired behavior behavior)


Stress Inoculation: Education/Rehearsal/Application/Follow Up. Teaching physical and cognitive coping skills. Procedures to help client identify and detect the precursors to anger, anxiety, pain, and depressive symptoms; teaching client to differentiate between justified and unnecessary symptoms/reactions; assisting client to recognize the early signs in the provocation sequence in order to gain better control over their symptoms. Includes helping client rehearse identified coping skills and debriefing following real exposure to the trigger.
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Stress Innoculation Training by Dr Meichenbaum