daily progress notes
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NOTE.docx
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:
Learn to Identify the early warnings signs of depressed mood and the preventative actions to take.
☐ Goal 2:
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☒ Inattentive ☐ Angry ☐ Sad ☐ Flat Affect ☐ Anxious, tense ☐ Positive Effect, mood☒ Oriented 3x ☒ Impulsive ☐ Labile ☐ Withdrawn ☐ Relates Well ☒ Decreased eye contact☐ Appropriate/ate eye contact☒ Other: |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
