Mental Health Affairs Progress Note Assistant-Progress Note Creation

Example

A therapist documents a client's reported mood, feelings, and personal observations during a session.

Scenario

In a scenario where a client discusses feeling overwhelmed at work, the assistant helps the therapist structure this subjective feedback into a coherent note that captures the client's emotional state, concerns, and any specific incidents that exacerbated their feelings.

Example

Recording measurable or observable client behaviors, such as attendance, engagement in session, and non-verbal cues.

Scenario

When a client shows signs of improved eye contact and more active participation in therapy sessions, the assistant guides the therapist in documenting these objective changes, providing a clear record of behavioral progress.

Example

Evaluating the client's progress in therapy, including improvements or setbacks in their mental health status.

Scenario

After several sessions focusing on coping strategies for anxiety, the therapist uses the assistant to assess the client's use and effectiveness of these strategies, noting any reduction in anxiety symptoms.

Example

Outlining future steps in the client's treatment, including any modifications to the therapy approach or new interventions.

Scenario

Based on the assessment that a client's anxiety has decreased but sleep disturbances persist, the assistant helps in planning to incorporate sleep hygiene techniques into the treatment plan.