daily progress notes
Psychosocial Rehabilitation Progress Note
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CLIENT NAME: |
Service Code: H2017 DIAGNOSIS: |
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Case #: |
Setting 53 CMHC GT |
Service Date: |
TOTAL UNITS: 16 |
Total hours: 4 |
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Begin-End Time |
8:00AM TO 9:00AM |
9:00AM TO 10:00AM |
10:00AM TO 11:00AM |
11:00AM TO 12:00PM |
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Session Number/units |
Section 1: 4 Units |
Section 2: 4 Units |
Section 3: 4 Units |
Section 4: 4 Units |
GOALS/OBJECTIVE ADDRESSED FROM CLIENTS TREATMENT PLAN:
☒ Goal 1:
Learn to Identify the early warnings signs of depressed mood and the preventative actions to take.
Decrease client’s overall anxiety symptoms and help client implement more positive behaviors that support decreased feelings and thoughts that produce anxiety.
☐ Goal 3:
Help client learn new ways to improve sleep patterns and increase overall restful sleep.
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OBSERVATIONS |
INTERVENTIONS UTILIZED |
PATIENT’S RESPONSE TO INTERVENTION |
ASSESSMENT OF PROGRESS/OUTCOME |
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Attentive ☒ Inattentive ☐ Angry ☐ Sad ☐ Flat Affect ☐ Anxious, tense ☐ Positive Effect, mood☒ Oriented 3x ☒ Impulsive ☐ Labile ☐ Withdrawn ☐ Relates Well ☒ Decreased eye contact☐ Appropriate/ate eye contact☒ Other: |
Individual Therapy ☐ PSR ☒ Behavior Modification ☐ Psychoeducation ☐ Conflict Mediation ☐ Cognitive/Behavioral ☐ Activity-Based Therapy ☐ Relaxation/Meditation ☐ Anger Management ☐ Social Skills ☐ Communication-relation Skills ☐ Treatment Progress Reviewed ☐ Career/Vocational Planning ☐ Other: |
Cooperative ☒ Uncooperative ☐ Assertive ☐ Passive ☐ Aggressive ☐ Non-Responsive ☐ Resistant ☐ Engaged/Active ☒ Variable ☒ Other: |
Minimal ☐ Slow ☒ Steady ☐ Good/Excellent ☐ Increased difficulties noted ☐ Complicated by recent stressors ☐ Developing insight ☒ Aware, Insightful ☐ Able to generate alternatives ☐ Initiates problem-solving ☒ Problem solved with the assistance ☒ Demonstrates empathy, support for others ☒ Uses sessions to vent ☒ Variable ☐ |
SKILL SETS ADDRESSED/ACTIVITIES PROVIDED BY FACILITATOR TO BUILD CLIENT SKILLS:
Activity facilitator’s intervention :
Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other: _______________
Activity facilitator’s intervention:
Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other: _______________
Activity 3:
Activity facilitator’s intervention :
Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other: _______________
Activity 4:
Activity facilitator’s intervention:
Participation: Cooperative ☒ Uninterested ☐ Distractible ☐ Confused ☐ Other: _______________
The client benefited by:
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Facilitator’s Signature/Credentials |
Clinical Director Name, /Credentials |
Date |
Psychosocial Rehabilitation Progress note 1