Clinical Progress Documentation Template

[Clinic Letterhead]
123 Health Street  
Wellness City, WC 45678  
(123) 456-7890  
(123) 456-7891  
Practitioner: Dr. Thomas Kelly, MD  
Surname: Smith  
First Name: John  
Date of Birth: 15/04/1980  
PROGRESS NOTE  
25 August 2024  
John Smith is a 43-year-old married male residing with his wife and two children. He is employed as an accountant and has been experiencing heightened stress due to work-related demands. He benefits from a supportive family environment and is actively engaged in community activities.
John has a history of generalized anxiety disorder and major depressive disorder, which have been managed with sertraline and cognitive-behavioral therapy (CBT). He has remained stable on his current medication regimen for the past six months, with no significant worsening of symptoms.
John attended the clinic alone today. He appeared well-groomed and was cooperative throughout the session. He maintained good eye contact and was articulate in expressing his concerns. His demeanor was calm, and he did not show any signs of agitation or distress.
John reported feeling generally stable in his mood, though he occasionally experiences feelings of worthlessness and hopelessness, particularly during high-stress periods at work. He denied any thoughts of self-harm or harm to others. He also denied experiencing any paranoia or hallucinations.
John has a strong support system, including his wife and close friends. He is actively involved in his children's lives and participates in their school activities. He manages household duties effectively and receives occasional help from his wife. John is also enrolled in the National Disability Insurance Scheme (NDIS) for additional support.
John is currently dealing with mild hypertension, which is being managed by his general practitioner. He has been advised to monitor his blood pressure regularly and maintain a healthy diet and exercise routine.
Plan and Recommendations:  
1. Continue current medication regimen (sertraline 100 mg daily).  
2. Continue with cognitive-behavioral therapy sessions bi-weekly.  
3. Maintain participation in NDIS programs.  
4. Monitor blood pressure regularly and follow up with the general practitioner.  
5. Schedule a follow-up visit in one month to monitor mental health stability.  
John was advised to maintain a balanced lifestyle, including regular physical activity and adequate hydration. He was also encouraged to practice stress management techniques, such as mindfulness and relaxation exercises.
Dr. Thomas Kelly, MD  
Consultant Psychiatrist