Procedure Documentation

Process:
- Presenting problems included anxiety and challenges in managing work-related stress.
- Progress achieved: Patient has effectively adopted breathing exercises to control anxiety, leading to a reduction in panic episodes.
- Setbacks: Patient experienced heightened stress due to a recent project deadline, temporarily increasing anxiety levels.
- Other discussions: Examined the effects of work stress on personal relationships and strategies to enhance communication with colleagues.
- Therapeutic techniques: Applied cognitive-behavioral therapy to address negative thought patterns.
- Assigned Homework: Engage in mindfulness meditation for 10 minutes daily.
Current functioning:
- Mood: Patient reports feeling more positive and less anxious.
- Sleep: Improved sleep patterns with 7-8 hours of restful sleep each night.
- Employment/Education: Employed full-time as a project manager.
- Family: Supportive family environment, with regular communication with siblings.
- Social: Active social life with regular outings with friends.
- Exercise/Physical Activity: Participates in yoga twice a week.
- Eating Regime/Appetite: Balanced diet with regular meals.
- Energy Levels: Consistent energy levels throughout the day.
- Recreational/Interests: Enjoys reading and hiking.
Presentation:
- Appearance: Well-groomed and appropriately dressed.
- Behaviour: Cooperative and engaged during the session.
- Speech: Clear and coherent.
- Mood: Calm and composed.
- Affect: Appropriate and congruent with mood.
- Perception: No hallucinations or dissociations reported.
- Thought Process: Logical and goal-directed.
- Thought Form: Organized and coherent.
- Orientation: Fully oriented to time and place.
- Memory: Intact short-term and long-term memory.
- Concentration: Good concentration levels.
- Attention: Attentive and focused.
- Judgement: Sound judgement capabilities.
- Insight: Good insight into condition and treatment.
Risk Assessment:
- Suicidal Ideation: No history or current ideation.
- Homicidal Ideation: None reported.
- Self-harm: No history of self-harm.
- Violence & Aggression: No incidents reported.
- Addictive Behaviours: No addictive behaviors noted.
- Risk-taking/Impulsivity: No significant risk-taking behaviors.
Treatment Plan:
- Goals for Treatment: Reduce anxiety levels and enhance stress management skills.
- Outcome Measures: Monitor anxiety levels through self-reported scales and therapist observations.
Session Summary: The patient has made notable progress in managing anxiety through breathing exercises and cognitive-behavioral techniques. Despite a temporary setback due to work-related stress, the patient remains optimistic and committed to the treatment plan. No current risk factors identified.
Supervision:
- Discussed the potential for exploring deeper underlying issues related to work stress and its impact on personal life.