The Mental Health Progress Note template by s10.ai is crafted for mental health professionals to meticulously document client sessions. Featuring sections for symptom description, objective content, supplementary notes, and treatment plans, this template enables counselors to detail symptoms, therapeutic interventions, and client progress, ensuring comprehensive session records. Perfect for monitoring mental health treatment plans and progress, this tool is indispensable for mental health practitioners utilizing s10.ai, the AI medical scribe. It enhances documentation efficiency, allowing counselors to dedicate more time to client care.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Symptom Description and Subjective Report:"The client endorsed the following symptoms"The client reported experiencing anxiety, difficulty sleeping, and feelings of sadness. These symptoms occur daily and last for several hours each time. The severity of symptoms is moderate, impacting the client's ability to concentrate at work and engage in social activities. The client reported that these symptoms have led to decreased productivity and withdrawal from social interactions.Objective Content:The client reported feeling overwhelmed by work responsibilities, experiencing tension in family relationships, and a lack of motivation. The client shared, "I feel like I'm constantly on edge and can't relax." The therapist used cognitive-behavioral therapy to address negative thought patterns, mindfulness exercises to reduce anxiety, and role-playing to improve communication skills. The client reported feeling more relaxed after the mindfulness exercises and expressed a willingness to try the role-playing techniques at home.Additional Notes / Assessment:The client has shown progress in managing anxiety through mindfulness practices. The session occurred at the therapist's office. The Beck Anxiety Inventory was administered, and the client scored a 22, indicating moderate anxiety.Plan:The ongoing plan for treatment includes continuing cognitive-behavioral therapy and practicing mindfulness exercises at home. The client was given homework to journal about daily stressors and practice deep breathing exercises. The topic of discussion for the next session will be stress management techniques, with an expectation to explore additional coping strategies. The next session is scheduled for 8 November 2024 at 10:00 AM, and it will be an individual therapy session.
Key advantages of using this template in clinical practice
Common questions about this template and its usage