Phrases for Progress Notes
Make this statement clinical for your 'impression section' of your note:
client arrives to session appearing sad, unshowered/unkempt, and speaking slowly with absence of emotion.
Client presented dishevelved with poor hygiene, using slow rate and flat affect.
What does 'means' in a risk assessment mean?
the way the person plans to execute a plan (ex. gun, knife, etc)
Stating exactly what a client or guardian reports in a session word for word.
Direct quote
What are three interventions from CBT?
journaling, reframing thoughts, mood tracker, etc.
What is pressured speech?
Speaking rapidly with little or no pause
Make this statement clinical for the 'session content/interventions' section of your note:
Therapist used worksheet about changing thoughts. Therapist had client review thoughts that upset them and ways to improve them.
Therapist used CBT intervention of refrraming automatic thoughts. Therapist aided client in identifying distressing thought patterns and ways to challenge them.
What is passive vs. active suicidal ideation?
Active-client is actively at risk of suicide and needs to be screened. They meet all criteria: means, access, intent, plan.
Why is it important to use person-first language?
Providing documentation that asserts individuals are seen as themselves, not that their diagnosis or behaviors defines who they are.
What are 3 interventions from DBT?
Wise mind, ACCEPTS, mindfulness, emotional regulation, etc.
How do you assess for 'orientation'?
Ask where the client is, what time/year it is, season, etc.
Make this therapy event clinical for the 'session content/interventions' section of your note:
Client played with toys in room and reenacted a bullying incident from school. Therapist watched client and gave feedback based off of play.
Therapist engaged client in play therapy activity to process negative event from school. Therapist assisted client with identifying safe school staff, and integrated alternative ending through utilization of play activity.
Millhill's measure to assess for suicidal ideation
C-SSRS
What is the difference between subjective and objective
Subjective information can differ between individuals, based off of personal influence and perspective
Objective information is based off of fact or evidence
Which theoretical orientation would the intervention of working on a 'target memory' to reduce trauma symptoms from PTSD be?
EMDR
What does a 'tangential' thought process mean?
Jumping from thought to thought with little or indirect connection between the thoughts.
Make this therapy event clinical for the 'session content/interventions' section of your note:
Client and their parent attended session together due to a recent argument at home. The client and their parent began yelling during the session and therapist intervened.
Therapist implemented family systems interventions to promote effective communication among family members. Additionally, therapist helped the family to address conflicts and facilitate a resolution.
Disclosing a patient or client's confidential information if they pose a danger to themselves or others.
Duty to warn
How would you identify individuals the client brings up during the session in your progress notes to maintain confidentiality?
Identify the relationship with the client "client's boyfriend", "client's youngest brother", "client's friend", etc.
Theory that uses intergenerational lens to identify these patterns and communication techniques to promote healthy boundaries and relationships within the family
Bowen Family Systems
What is 'poor remote' memory mean?
The memory of events that occurred in the distant past is a type of episodic memory referred to as remote or long term memory.
Make this therapy event clinical for the 'session content/interventions' section of your note:
Therapist and client played Uno during their initial session without the parent and got to know each other better during the session. While playing UNO client and therapist discussed different emotions depending on the color of the card played.
Therapist and client spent the session building therapeutic rapport. Client and therapist played UNO during the session and practiced emotion identification and emotional intelligence skills during the game
What are three examples of behaviors that may suggest a person is contemplating ending their life
Giving away personal items, drastic improvement in mood, visiting or calling people to say goodbye, significant change in sleeping habits, withdrawing from typical activities, etc.
Are you able to use short hand and abbreviations in your progress notes?
Which theory utilizes these four stages: Encouragement, Assessment, Insight, Reorientation.
Adlerian Therapy
What is the difference between a delusion and a hallucination?
A delusion is a thought/belief and a hallucination is a sensory perception.