Behavioral Therapy Documentation

SUBJECTIVE:  
Chief Complaint:  
pt. presented with: anxiety and difficulty managing stress  
TOPIC/THEME DISCUSSED:  
Coping mechanisms for anxiety, stress management techniques  
SYMPTOMS AND SIGNS OF DISTRESS:  
Increased heart rate, restlessness, difficulty concentrating  
AREAS OF IMPAIRMENT:  
Work performance, social interactions  
ISSUES/STRESSORS:  
"I feel overwhelmed at work and can't focus on tasks."  
TARGET PROBLEMS:  
Anxiety management, stress reduction  
TREATMENT OBJECTIVES:  
Improve coping skills, enhance focus and productivity  
History Of Present Illness:  
Patient has a history of generalized anxiety disorder, exacerbated by recent job changes and increased workload.  
Social History:  
Suicide/Violence Risk: denies  
Danger to Others: denies  
Child Abuse: denies  
Safety Plan: call therapist, talk to someone, call 911  
Current Medications:  
Name of Medication: Sertraline Dosage: 50mg  
Review of System:  
Nervous system: reports increased anxiety, Cardiovascular: increased heart rate  
OBJECTIVE:  
Objective Notes:  
Mental status is within normal limits unless otherwise specified  
Strengths:  
Patient demonstrates strong problem-solving skills and a supportive social network  
ASSESSMENT:  
Diagnosis:  
ICD-10 Codes:  
F41.1 Generalized Anxiety Disorder  
Diagnostic Assessments:  
No new diagnoses noted  
PLAN:  
Procedures:  
Cognitive Behavioral Therapy, Relaxation techniques, Coping Skills development  
Procedure Notes:  
Cognitive Behavioral Therapy to address anxiety, focus on relaxation techniques  
Goal: Reduce anxiety symptoms, improve stress management  
Care Plan:  
Regular therapy sessions, practice relaxation techniques, engage in physical activity  
response to treatment:  
TREATMENT COMPLIANCE: compliant  
RESPONSE TO TREATMENT: positive  
transferred from s10.ai