Professional Documents
Culture Documents
Sample
1/26/2016
ID: 1
Page #: 1
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Clinical Record
Name:
Judy A. Sample
Provider:
Default Provider
Date:1/26/2016
Personal Data
ID: 1
Address: 111 Main St.
City:
State/Province:
Zip/Postal Code:
Home Phone:
Work Phone:
SSN:
Anywhere
MI
11111
(555)555-5555
(555)555-5555
555-55-5555
Birth Date:
Age:
Gender:
Race:
Marital Status:
Military Rank:
Treatment Start Date:
Treatment End Date:
Last Review:
Treatment Status:
Previously Treated?:
Pri. Care Physician:
Employer:
Referral Source:
Psychiatrist:
Setting:
Department:
7/7/1946
69
Female
Caucasian
Married
NA
8/7/2006
Active
No
Dr Smith
Sue Jackson
Outpatient
East Paris
Authorization Data
Insurance Carrier
Aetna
Date Authorized
8/7/2006
Start Date
8/7/2006
End Date
11/7/2006
Sessions Used:
Authorized Sessions
6
Authorization Number
989887
Sessions Remaining:
Assessment
Interviewer:
Default Provider
Interview Date:
8/7/2006
Person Interviewed:
Patient
Psychosocial History:
Family:
Judy indicates that her father was an anxious man who worried about everything. Judy was close to him while she
lived at home. Judy has been married to Bob for 40 years and they have two daughters who are married and live
close to Judy. She has a good relationship with her husband and her daughters. Judy enjoys working in her garden
but would like to entertain her friends more if she was not so preoccupied with worry.
Developmental:
N/A
Substance Use:
Judy denies any problems with use of alcohol or other mood altering drugs. There is no history of substance use
disorder in her family of origin nor with her husband.
Socio-Economic:
Judy and Bob live alone in their own home. Bob is employed as engineer at a large corporation. Judy was working as
a school secretary until two years ago when she quit due to her overwhelming worries. She denies any significant
financial problems but she does worry about their retirement finances. She and Bob attend church services quite
regularly but she fears that God does not hear her prayers for peace of mind.
Psychiatric:
Judy has never been in counseling before but her father was admitted to a psychiatric hospital one time for about two
weeks several years ago. Judy has been on Xanax from her Ob-Gyn physician, Dr. Cole, for several months.
Medical:
Judy complains of severe pain her back that has been with her for two years. She has been told that surgery will not
help. She worries that it may be something serious like cancer that has not been found.
Strengths/Weaknesses
ID: 1
Page #: 2
SSN: 555-55-5555
Birthday: 7/7/1946
Strengths:
Stable Work History, Positive Support Network, Motivated for Change
Weaknesses:
Poor Health, Indecisive
Assessments Completed:
Instrument/Interview: Clinical Interview
Date Administered: 8/7/2006
Result:
Details:
Interpretation Note:
Mental Status:
Presentation
Appearance:
Mood:
Attitude:
Affect:
Speech:
Motor Activity:
Orientation:
Mental Functioning
Simple Calculations:
Serial Sevens:
Immediate Memory:
Remote Memory:
General Knowledge:
Proverb Interpretation:
Similarities/Differences:
Well-Groomed
Anxious
Cooperative
Appropriate
Pressured
Tense
Fully Oriented
Date First Rated: 8/7/2006
Accurate
Accurate
Intact
Intact
Accurate
Accurate
Accurate
Date:
Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:
Risk Assessment
ID: 1
SSN: 555-55-5555
Page #: 3
Date First Rated: 8/7/2006
Birthday: 7/7/1946
Date Last Rated:
Intact
Intact
High
Date First Rated: 8/7/2006
Suicide:
Violence:
Child Abuse:
Partner Abuse:
Elder/Parent Abuse:
Latest Note:
8/7/2006
None
None
None
None
None
Assessment Summary:
Recovery Assessment ASAM Patient Placement Criteria 2R:
Date: 8/21/2006
Six Dimensions
I.
Acute Intoxication and/or Withdrawal Potential
II.
Biomedical Conditions & Complications
III.
Emotional / Behavioral or Cognitive Conditions & Complications
IV.
Readiness to Change
V.
Relapse, Continued Use or Continued Problem Potential
VI.
Recovery / Living Environment
Level of Care:
Comment:
Stage of Change
Preparation
Diagnosis
Axis I
300.02
Axis II
V71.09
No Diagnosis
Axis III
Axis IV
Axis V
Comment
Comment
Severity
Medium
Low
High
Medium
Low
High
Date:
ID: 1
Page #: 4
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Treatment Techniques
Treatment Modalities:
CPT Code
90806
Type
Indiv. OP Psychotherapy-45" no Med. Eval
Recommended
Level of care
Outpatient
Least Restrictive
Alternative?
Yes
Frequency
1 Weekly
Agreement with
level of care?
Yes
Provider
Default Provider
Is recommended level
of care available?
Yes
Modality Note:
Treatment Approaches:
The following treatment approaches are being implemented:
Cognitive Restructuring, Behavioral Techniques
Approach Note:
Medication: Xanax
Start Date: 8/7/2006
Note:
Dosage: 5mg.
End Date:
Frequency: 1x/day
Prescribed by: Dr.Jones
Presenting Problems
Primary Anxiety
Secondary Chronic Pain
Treatment Plan
Primary Problem:
Behavioral Definition
Anxiety
Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a
number of events or activities.
Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying
asleep, exhibiting a general state of irritability).
Long-term Goals
Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.
Describe current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning
and attempts to resolve it.
Entry Date: 8/7/2006
Target Date:
Projected Sessions:
Critical?: No
Assess the focus, excessiveness, and uncontrollability of the client's worry and the type, frequency,
intensity, and duration of her anxiety symptoms (e.g., The Anxiety Disorders Interview Schedule for the
DSM-IV by DiNardo, Brown, and Barlow).
Entry Date: 8/7/2006
Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.
Entry Date: 8/7/2006
Target Date:
Projected Sessions:
Critical?: No
Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various
ID: 1
Page #: 5
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that
interact to maintain the problem (see Mastery of Your Anxiety and Worry - Therapist Guide by Craske,
Barlow, and O'Leary).
Entry Date: 8/7/2006
Provider:
Provider:
Use biofeedback techniques to facilitate the client's success at learning relaxation skills.
Entry Date: 8/7/2006
Critical?: No
Assign the client homework each session in which she practices relaxation exercises daily; review and
reinforce success while providing corrective feedback toward improvement.
Entry Date: 8/7/2006
Projected Sessions:
Teach the client relaxation skills (e.g., progressive muscle relaxation, guided imagery, slow diaphragmatic
breathing) and how to discriminate better between relaxation and tension; teach the client how to apply
these skills to her daily life (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Treating
GAD by Rygh and Sanderson).
Entry Date: 8/7/2006
Provider:
Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books
or treatment manuals (e.g., Progressive Relaxation Training by Bernstein and Borkovec; Mastery of Your
Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow, and O'Leary).
Entry Date: 8/7/2006
Provider:
Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety
symptoms.
Entry Date: 8/7/2006
Target Date:
Projected Sessions:
Critical?: No
Assist the client in analyzing her fear by examining the probability of the negative expectation occurring,
the real consequences of it occurring, her ability to control the outcome, the worst possible outcome, and
her ability to accept it (see "Analyze the Probability of a Feared Event" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma, and Anxiety Disorders and Phobias by Beck and Emery).
Entry Date: 8/7/2006
Provider:
Provider:
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk.
Entry Date: 8/7/2006
Target Date:
Critical?: No
Provider:
Teach the client to implement a thought-stopping technique (thinking of a stop sign and then a pleasant
scene) for worries that have been addressed but persist (or assign "Making Use of the Thought-Stopping
Technique" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); monitor and encourage the
client's use of the technique in daily life between sessions.
Entry Date: 8/7/2006
Projected Sessions:
Explore the client's schema and self-talk that mediate her fear response; challenge the biases; assist her in
replacing the distorted messages with reality-based alternatives and positive self-talk that will increase her
self-confidence in coping with irrational fears.
Entry Date: 8/7/2006
Provider:
Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.
Provider:
Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry
effectively and reduce overarousal and unnecessary avoidance.
Provider:
Assign the client to read psychoeducational sections of books or treatment manuals on worry and
generalized anxiety (e.g., Mastery of Your Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow,
and O'Leary).
Provider:
Provider:
Undergo gradual repeated imaginal exposure to the feared negative consequences predicted by worries and develop
alternative reality-based predictions.
Entry Date: 8/7/2006
Target Date:
Critical?: No
Provider:
Select initial exposures that have a high likelihood of being a success experience for the client; develop a
plan for managing the negative affect engendered by exposure; mentally rehearse the procedure.
Entry Date: 8/7/2006
Projected Sessions:
Direct and assist the client in constructing a hierarchy of two to three spheres of worry for use in exposure
(e.g., worry about harm to others, financial difficulties, relationship problems).
Provider:
Assign the client a homework exercise in which she does worry exposures and records responses (see
Mastery of Your Anxiety and Worry - Client Guide by Zinbarg, Craske, Barlow, and O'Leary or
ID: 1
Page #: 6
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Generalized Anxiety Disorder by Brown, O'Leary, and Barlow); review, reinforce success, and provide
corrective feedback toward improvement.
Target Date:
Secondary Problem:
Behavioral Definition
Projected Sessions:
Critical?: No
Support the client in following-through with work, family, and social activities rather than escaping or
avoiding them to focus on panic.
Entry Date: 8/7/2006
Provider:
Provider:
Chronic Pain
Has decreased or stopped activities such as work, household chores, socializing, exercise, sex, or other pleasurable
activities because of pain.
Makes statements like "I can't do what I used to"; "No one understands me"; "Why me?"; "When will this go away?"; "I
can't take this pain anymore"; and "I can't go on."
Complains of generalized pain in many joints, muscles, and bones that debilitates normal functioning.
Long-term Goals
Regulate pain in order to maximize daily functioning and return to productive employment.
Describe the nature of, history of, impact of, and understood causes of chronic pain.
Entry Date: 8/7/2006
Target Date:
Provider:
Target Date:
Projected Sessions:
Critical?: No
Ask the client to complete a medication review with a specialist in chronic pain or headaches; confer with
the physician afterward about her recommendations and process them with the client.
Entry Date: 8/7/2006
Provider:
Target Date:
Projected Sessions:
Critical?: No
Form a small, closed enrollment group (4-8 clients) for pain management (see Group Therapy for Patients
with Chronic Pain by Keefe, Beaupre, Gil, Rumble, and Aspnes).
Entry Date: 8/7/2006
Provider:
Provider:
Complete a thorough medication review by a physician who is a specialist in dealing with chronic pain or headache
conditions.
Critical?: No
Explore the changes in the client's mood, attitude, social, vocational, and familial/marital roles that have
occurred as a result of the pain.
Projected Sessions:
Assess the history and current status of the client's chronic pain.
Target Date:
Projected Sessions:
Critical?: No
Teach the client self-monitoring of her symptoms; ask the client to keep a pain journal that records time of
day, where and what she was doing, the severity, and what was done to alleviate the pain (or assign "Pain
and Stress Journal" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); process the journal
with the client to increase insight into nature of the pain, cognitive, affective, and behavioral triggers, and
the positive or negative effect of the interventions they are currently using.
Entry Date: 8/7/2006
Provider:
Learn and implement somatic skills such as relaxation and/or biofeedback to reduce pain level.
Entry Date: 8/7/2006
Target Date:
Provider:
Provider:
Assign a homework exercise in which the client implements somatic pain management skills and records
the result; review and process during the treatment session.
Entry Date: 8/7/2006
Critical?: No
Identify areas in the client's life that she can implement skills learned through relaxation or biofeedback.
Entry Date: 8/7/2006
Projected Sessions:
Teach the client relaxation skills (e.g., progressive muscle, guided imagery, slow diaphragmatic breathing)
and how to discriminate better between relaxation and tension; teach the client how to apply these skills to
her daily life (see Progressive Relaxation Training by Bernstein and Borkovec).
Provider:
Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books
ID: 1
Page #: 7
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Target Date:
Critical?: No
Provider:
Assign the client a homework exercise in which she identifies negative pain-related self-talk and positive
alternatives (or assign "Journal and Replace Self-Defeating Thoughts" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma); review and reinforce success, providing corrective feedback toward
improvement.
Entry Date: 8/7/2006
Projected Sessions:
Explore the client's schema and self-talk that mediate her pain response, challenging the biases; assist her in
generating thoughts that correct for the biases, facilitate coping, and build confidence in managing pain.
Entry Date: 8/7/2006
Provider:
Identify negative pain-related thoughts and replace them with more positive coping-related thoughts.
Provider:
Assign the client to read about cognitive restructuring in relevant books or treatment manuals (e.g., The
Chronic Pain Control Workbook by Catalano and Hardin).
Entry Date: 8/7/2006
Provider:
Integrate and implement new mental, somatic, and behavioral ways of managing pain.
Entry Date: 8/7/2006
Target Date:
Projected Sessions:
Critical?: No
Assist client in integrating learned pain management skills (e.g., relaxation, distraction, activity scheduling)
into a progressively wider range of daily activities; record and review.
Entry Date: 8/7/2006
Provider:
Response to Plan
Response to treatment plan presentation:
Significant Other response to treatment plan presentation:
I, Judy A. Sample, have reviewed this treatment plan.
x. _______________________________________________
Date: ______________________________
Progress Notes
Session 1
Date: 8/7/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy
(60 min)
Provider Signature:
1/26/2016
Date
Default Provider
Session 2
Date: 8/14/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy
(60 min)
Progress Rating:
CPT Code:
1/26/2016
Date
Default Provider
Session 3
Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy
(30 min)
1/26/2016
Date
Objective Ratings
Objectives Identified
Describe current and past experiences with the worry and anxiety symptoms, complete
with their impact on functioning and attempts to resolve it.
Verbalize an understanding of the cognitive, physiological, and behavioral components
of anxiety and its treatment.
Learn and implement calming skills to reduce overall anxiety and manage anxiety
symptoms.
Verbalize an understanding of the role that cognitive biases play in excessive irrational
worry and persistent anxiety symptoms.
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and
empowering self-talk.
Undergo gradual repeated imaginal exposure to the feared negative consequences
predicted by worries and develop alternative reality-based predictions.
Maintain involvement in work, family, and social activities.
Describe the nature of, history of, impact of, and understood causes of chronic pain.
Complete a thorough medication review by a physician who is a specialist in dealing
with chronic pain or headache conditions.
Participate in a cognitive behavioral group therapy for pain management.
Identify and monitor specific pain triggers.
Learn and implement somatic skills such as relaxation and/or biofeedback to reduce
pain level.
Identify negative pain-related thoughts and replace them with more positive copingrelated thoughts.
Integrate and implement new mental, somatic, and behavioral ways of managing pain.
Critical?
No
First Progress
Rating:
8/7/2006
No Change
Last Progress
Rating:
8/23/2006
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No
No
No Change
No Change
No Change
No Change
No Change
No Change
No
No
No
No Change
No Change
No Change
No Change
No Change
No Change
No
No Change
No Change
No
No Change
No Change
Prognosis
Prognosis Rating of successful
achievement of Goals
Good
% of Critical Objectives
Achieved by Treatment End
70%
Judy is strongly motivated to work on her issues and she has a good support network.
ID: 1
Page #: 9
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Discharge
Discharge Criteria:
Mood, behavior and thought stabilized sufficiently to independently carry out basic self-care.
Verbalizes names of supportive resources who can be contacted if feeling suicidal/homicidal.
Hallucinations or delusions controlled enough to not interfere with basic self-care.
Competent
Competent
Outpatient Therapy
Self Care
Return to full-time job
Provider Credentials
Default Provider
Supervisor
Default Provider
License:
License:
Treatment Team:
Clinical Staff
Default Provider
Requested Amendments
Request Date: 8/7/2006
Section: Progress
Reason for Denial:
Person Approving/Denying: Jongsma, Arthur E (PhD)
Amendment:
Approved: Yes
Person Requesting:
Judy wants to point out that she has always been tense and fearful.
Disclosure Authorizations
Patient was provided PHI Privacy Notice: Yes
Patient signed PHI Privacy Acknowledgement: Yes
Patient Has Not Signed but Receipt of Form was Witnessed: No
Date: 8/7/2006
Authorization on File:
Address:
General Notes
Yes
To Whom:
Bill Allen
City: Fastoo
ID: 1
Page #: 10
SSN: 555-55-5555
Birthday: 7/7/1946
Date: