OUT OF SESSION TASK REVIEW:
- [Detail the client's practice of skills, strategies or reflection from the last session]. (use as many bullet points as needed to capture all the details of the client’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail the client's report on the completion and effectiveness of these tasks]. (use as many bullet points as needed to capture all the details of the client’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail any challenges or obstacles faced by the client in completing these tasks?]. (use as many bullet points as needed to capture all the details of the client’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
CURRENT PRESENTATION:
- [Detail the client’s current presentation, including symptoms and any new arising issues]. (use as many bullet points as needed to capture all the details of the client’s symptoms and issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail any changes in symptoms or behaviors since the last session]. (use as many bullet points as needed to capture all the details of the client’s symptoms and issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
SESSION CONTENT:
- [Describe any issues raised by the client.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe details of relevant discussions with client during the session.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe the therapy goals/objectives discussed with client.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Describe the progress achieved by client towards each therapy goal/objective.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail the main topics discussed during the session, any insights or realizations by the client, and the client's response to the discussion]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
INTERVENTION:
- [Detail the specific therapeutic techniques and interventions used or to be used, for example, CBT, Mindfulness Based CBT, ACT, DBT, Schema Therapy, or EMDR.] (use as many bullet points as needed to capture all the details discussed. ) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Detail the specific techniques or strategies used and the client's engagement with the interventions.]. (use as many bullet points as needed to capture all the details discussed. ) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
SETBACKS/ BARRIERS/ PROGRESS WITH TREATMENT
- [Describe the setbacks, barriers, obstacles, or progress for each therapy goal/objective]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail the client’s comments on their satisfaction with treatment]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).]
RISK ASSESSMENT AND MANAGEMENT:
- Suicidal Ideation: [describe any history of suicidal ideation, attempts, plans in detail]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Homicidal Ideation: [Describe any homicidal ideation]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Self-harm: [Detail any history of self-harm]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- Violence & Aggression: [Describe any recent or past incidents of violence or aggression]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Management Plan: [Describe strategy or steps taken to manage suicidal ideation / homicidal ideation / self-harm / violence & aggression (if applicable)]. (use as many bullet points as needed to capture all the details discussed) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
MENTAL STATUS EXAMINATION:
Appearance: [Describe the client's clothing, hygiene, and any notable physical characteristics]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Behaviour: [Observe the client's activity level, interaction with their surroundings, and any unique or notable behaviors]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Speech: [Note the rate, volume, tone, clarity, and coherence of the client's speech]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Mood: [Record the client's self-described emotional state]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
Affect: [Describe the range and appropriateness of the client's emotional response during the examination, noting any discrepancies with the stated mood]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Thoughts: [Assess the client's thought process and thought content, noting any distortions, delusions, or preoccupations]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the client]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
Cognition: [Describe the client's memory, orientation to time/place/person, concentration, and comprehension]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
Insight: [Describe the client's understanding of their own condition and symptoms, noting any lack of awareness or denial]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
Judgment: [Describe the client's decision-making ability and understanding of the consequences of their actions]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).
OUT OF SESSION TASKS
- [Detail any tasks or activities assigned to the client to complete before the next session and the reasons for the tasks]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PLAN FOR NEXT SESSION
- Next Session: [mention date and time of next session]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Detail the specific topics or issues to be addressed at the next session, any planned interventions or techniques to be used]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)