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Therapists
15-20 minutes

Dialectical Behavior Therapy (DBT) Documentation

The s10.ai DBT Therapy Note template is expertly crafted for mental health professionals to efficiently document Dialectical Behavior Therapy sessions. This comprehensive template features sections for capturing the client's mood, involvement in mindfulness exercises, and participation in psychoeducation. It also facilitates detailed recording of clinician interventions and homework assignments, ensuring thorough and organized notes. By adopting this template with s10.ai, the AI medical scribe, clinicians can streamline their documentation process, allowing for enhanced focus on client care and improved tracking of therapeutic progress.

2,957 uses
4.5/5.0
J
Jonathan Blake
Template Structure

Organized sections for comprehensive clinical documentation

Symptom Overview and Subjective Account
[Provide a description of the client's presentation and mood]
[Describe the client's participation in mindfulness exercises](do not make assumption and write in details)
[Detail any homework review or lack thereof](do not make assumption and write in details)
[Outline the client's participation in psychoeducation](do not make assumption and write in details)
Objective Information
[Describe the mindfulness exercise presented by the clinician](do not make assumption and write in details)
[Mention any homework review or lack thereof](do not make assumption and write in details)
[Detail the psychoeducation content presented by the clinician](do not make assumption and write in details)
[Describe any homework assigned by the clinician](do not make assumption and write in details)
Interventions Implemented
[List the interventions use]
Sample Clinical Note

Example of completed documentation using this template

Symptom Description and Subjective Report  
The client, a 28-year-old female, arrived with a depressed mood and mentioned feeling overwhelmed by everyday stressors. She seemed anxious and struggled to maintain eye contact. During the session, the client engaged in mindfulness exercises, although she initially expressed hesitation. She was led through a breathing exercise and reported feeling somewhat more relaxed afterward. The client did not complete the homework assigned from the previous session, citing a lack of time and motivation. In psychoeducation, the client participated actively, asking questions about techniques for emotional regulation.
Objective Content  
The clinician introduced a mindfulness exercise centered on deep breathing and grounding techniques. The client was encouraged to concentrate on her breath and bodily sensations. The homework review showed that the client had not attempted the assigned tasks, which included journaling her emotions. The psychoeducation content covered the fundamentals of emotional regulation and distress tolerance skills. The clinician assigned new homework, which involved practicing the breathing exercise daily and journaling her experiences.
Interventions Used  
- Mindfulness breathing exercise  
- Psychoeducation on emotional regulation  
- Homework assignment: daily mindfulness practice and journaling
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "Symptom Description and Subjective Report" clinical template is an essential tool for healthcare professionals seeking to enhance patient care through structured documentation. This template allows clinicians to meticulously capture the client's presentation and mood, ensuring a comprehensive understanding of their mental health status. It facilitates detailed documentation of the client's engagement in mindfulness exercises, providing insights into their participation and progress. Additionally, the template supports thorough reviews of any assigned homework, highlighting areas of compliance or need for improvement. By outlining the client's involvement in psychoeducation, clinicians can better tailor therapeutic approaches to individual needs. The "Objective Content" section empowers clinicians to document the mindfulness exercises presented, review homework assignments, and detail psychoeducation content, ensuring a holistic approach to patient care. The "Interventions Used" section allows for precise recording of therapeutic interventions, promoting continuity of care and facilitating outcome tracking. Adopt this template to streamline clinical workflows, enhance patient engagement, and improve therapeutic outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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Dialectical Behavior Therapy (DBT) Documentation