Progress Note, Diagnostic Evaluation, and Diagnosis Training

Progress notes are essential documentation tools in clinical practice, providing a detailed record of a client’s sessions. They are completed after each session on our EHR software, SimplePractice.

In this training, you’ll practice filling out a progress note as if you’ve just seen a client. You will create a fictional pseudo-client. To create your pseudo-client, refer to the intake assessment forms provided below; the rest is for your imagination. Use the information in these forms to build a detailed client profile, including their background, presenting issues, and assessment scores. Be sure to craft a realistic profile that matches the provided forms.

PHQ-9, Cage-AID, SBQ, ACE, GAD-7, and the initial assessments are the intake paperwork the patient fills. The paperwork below is from a pseudo patient. Please refer to them while filling out some of the parts of the form.

Supportive Documents:

Clinician Name *

Anxious / Depressive Symptoms Ratings

Levels of Anxious Symptoms (0-10)

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10

Levels of Depressive Symptoms (0-10)

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10

Diagnostic Evaluation

Presenting Problems: *

• Anxiety/Worry
• Panic attacks
• Poor impulse control
• Agitation/Restlessness
• Depression
• Anger/Irritability
• Hypervigilance
• Pain
• Fatigue/Low energy
• Sleep disturbance
• Intrusive thoughts
• Obsessive thoughts
• Grief
• Isolation/Loneliness
• Work/Career
• Identity issues
• Trauma
• Interpersonal relationship conflict
• Other

What is the client's Diagnosis & what are the Signs and Symptoms (DSM-V-TR based) resulting in impairment(s): (Include current examples for treatment planning, e.g., social, occupational, affective, cognitive, physical) *

resulting treatment Clinician

How are symptoms currently impacting functioning? *

Treatment Plan

When was this Treatment Plan Established or Revisited? (EXPIRES 90-DAYS) *

Goal of Treatment (Tx Plan goals): GOAL/ OBJECTIVE/ INTERVENTIONS/FREQUENCY *

Treatment Plan Progress *

• Marked improvement
• Maintenance of functioning
• Significant reduction in symptoms
• Actively engaged in treatment
• Resistant in tx

Treatment Recommendation *

• Continue Current Therapeutic Focus
• Change Treatment Goals or Objectives
• Terminate Treatment

Session Note Details

Data / Session Focus

• Homework Assignment
• History/Background
• Stressor/Coping Mechanism
• Familial Relationship
• Identity
• Work/School Problems
• Financial Issues
• Legal Issues
• Substance Use
• Trauma Experience
• Peer Relationship
• Marital/Partner Issues
• Self Esteem
• Parenting
• Self Care
• Attachment
• Sexual Issues
• Sexual Abuse
• Domestic Violence
• Health Issues
• Boundary Setting
• Symptom Management
• Other

Interventions *

• Cognitive Challenging
• Cognitive Refocusing
• Cognitive Reframing
• Communication Skills
• DBT Strategies
• Exploration of Coping Patterns
• Explanation of Relationship Patterns
• Guided Imagery
• Interactive Feedback
• Interpersonal Resolutions
• Mindfulness Training
• Preventative Services
• Insight Development
• Cognitive Behavioral
• Supportive Reflection
• Psycho-education
• Safety Planning
• Motivational Interviewing
• AIP History Taking
• EMDR TICES Log
• EMDR Target Selection
• Floatback Technique
• Affect Scan
• Bilateral Stimulation BLS
• Safe/Calm Place Script
• Resourcing Script
• Eye Movement Desensitization Protocol EMD
• Gottman Rapaport
• Fourhorsemen
• Aftermath of a Fight
• Oral History
• Gottman Treatment Planning
• Sound Relationship House
• Other Gottman Related Strategies
• Other EMDR related strategies
• Other

Progress Note: (issues presented in session by pt; therapist observations of symptoms; interventions utilized; response from patient; plan for future sessions)

Medical Necessity Factors Influencing Length a/o Frequency of sessions to avoid higher levels of care or longer/ more frequent outpatient sessions *

• Rapport Building with New Client
• Client Request for additional session time a/o increased frequency
• History of Trauma
• Client Crisis/Acute Issues
• Time necessary to address and contain intense emotional content
• Preventative measure to avoid higher level of care
• Necessary for therapeutic intervention utilized in session
• Addressing new or re-emerging symptoms
• Limited healthy support network
• Client is unable to share content with others in support system due to nature of topic
• EMDR Protocol being utilized
• DBT Protocol being utilized
• Symptoms are impacting multiple domains of life (relationships, work, school, community)
• N/A

Assessments, Tools, Screeners, Etc given and results

PHQ-9 Score:

GAD-7 Score:

CAGE Responses:

SBQ Risk Level:

ACE Score:

PTSD – Checklist Answers

ADHD Screening Answers

Crisis Protocol: Suicide-Homicidal Assessment

Other; explain

Mental Status Exam

Attention/Cognition *—AlertDistractedPoor/DisorganizedOrientedWNLN/A

Affect *

• Appropriate
• Labile
• Expansive
• Constricted
• Blunted
• Flat
• N/A
• Other

Mood *

• WNL
• Euthymic
• Dysphoric
• Euphoric
• Happy
• Sad
• Despondent
• Irritable
• Anxious
• Angry
• Depressed
• N/A
• Other

Other *

Appearance *—WNLDisheveledWell-groomedN/A

Motor Activity *—WNLPoor PostureErraticTremorsAbnormal MovementsN/A

Thought Process *—Logical & LinearCoherentGoal DirectedDisorganizedCircumstantialWNLN/A

Delusions *—None PresentPresentN/A

Memory *—WNLIntactPoorFairN/A

Insight *—FairPoorGoodN/A

Judgement *—FairPoorGoodN/A

Orientation *—FairPoorGood (person, place, time & situation)WNLN/A

Speech *—WNLNormalPressuredDecreasedStutteringN/A

Medication Compliance & Status

Medications *

Medication Compliance *

• Yes
• No
• Referral Made
• N/A

Substance Use Assessment

Substance Use *

• Yes
• None
• Denied Use
• Did not Assess

Substance Use Assessment & Relevant Content *

Safety Issues / Risk Assessment

Safety Issues / Risk Assessment *

• No SI/HI reported
• Suicidal Ideation
• Homicidal Ideation
• Self Harm
• High: Referred to ER
• Low/Moderate: Referred to higher level of care evaluation
• Safety Plan Created
• Safety Plan Reviewed
• Crisis Protocol: Suicidal Homicidal Ideation Assessment

Describe

Diagnosis 1 *

Please refer to the ICD-10 and DSM-5

Diagnosis 2 (optional)

Date / Time

Date

Time

Signature

Clear Signature

Submit