Sample
1/26/2016
ID: 1
Page #: 1
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Clinical Record
Name:
Judy A. Sample
Provider:
Default Provider
Date:1/26/2016
Personal Data
ID: 1
Address: 111 Main St.
City:
State/Province:
Zip/Postal Code:
Home Phone:
Work Phone:
SSN:
Anywhere
MI
11111
(555)555-5555
(555)555-5555
555-55-5555
Birth Date:
Age:
Gender:
Race:
Marital Status:
Military Rank:
Treatment Start Date:
Treatment End Date:
Last Review:
Treatment Status:
Previously Treated?:
Pri. Care Physician:
Employer:
Referral Source:
Psychiatrist:
Setting:
Department:
7/7/1946
69
Female
Caucasian
Married
NA
8/7/2006
Active
No
Dr Smith
Sue Jackson
Outpatient
East Paris
Authorization Data
Insurance Carrier
Date Authorized
Start Date
End Date
Authorized Sessions
Authorization Number
Aetna
8/7/2006
8/7/2006
11/7/2006
989887
Sessions Used:
Sessions Remaining:
Assessment
Interviewer:
Default Provider
Interview Date:
8/7/2006
Person Interviewed:
Patient
Psychosocial History:
Family:
Developmental:
Substance Use:
Socio-Economic
Psychiatric:
Medical:
Judy indicates that her father was an anxious man who worried about everything. Judy was close to
him while she lived at home. Judy has been married to Bob for 40 years and they have two
daughters who are married and live close to Judy. She has a good relationship with her husband and
her daughters. Judy enjoys working in her garden but would like to entertain her friends more if she
was not so preoccupied with worry.
N/A
Judy denies any problems with use of alcohol or other mood altering drugs. There is no history of
substance use disorder in her family of origin nor with her husband.
Judy and Bob live alone in their own home. Bob is employed as engineer at a large corporation. Judy
was working as a school secretary until two years ago when she quit due to her overwhelming
worries. She denies any significant financial problems but she does worry about their retirement
finances. She and Bob attend church services quite regularly but she fears that God does not hear
her prayers for peace of mind.
Judy has never been in counseling before but her father was admitted to a psychiatric hospital one
time for about two weeks several years ago. Judy has been on Xanax from her Ob-Gyn physician,
Dr. Cole, for several months.
Judy complains of severe pain her back that has been with her for two years. She has been told that
surgery will not help. She worries that it may be something serious like cancer that has not been
found.
Strengths/Weaknesses
Birthday: 7/7/1946
Assessments Completed:
Instrument/Interview
Date
Administered
Data Source
Result
Clinical Interview
Psychosocial History
Global Severity Index
8/7/2006
8/7/2006
8/7/2006
Patient
Patient
Patient
22.00
8/14/2006
Patient
11.00
9/11/2006
Patient
7.00
Treatment
Phase
Details
PreTreatment
During
Treatment
PostTreatment
Interpretation Note:
Mental Status:
Presentation
Appearance:
Mood:
Attitude:
Affect:
Speech:
Motor Activity:
Orientation:
Mental Functioning
Simple Calculations:
Serial Sevens:
Immediate Memory:
Remote Memory:
General Knowledge:
Proverb Interpretation:
Similarities/Differences:
Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:
Risk Assessment
Accurate
Accurate
Intact
Intact
Accurate
Accurate
Accurate
Date First Rated: 8/7/2006
Intact
Intact
High
Date First Rated: 8/7/2006
Suicide:
Violence:
Child Abuse:
Partner Abuse:
Well-Groomed
Anxious
Cooperative
Appropriate
Pressured
Tense
Fully Oriented
None
None
None
None
Latest Note:
Date:
ID: 1
Page #: 3
None
SSN: 555-55-5555
Birthday: 7/7/1946
Assessment Summary:
Recovery Assessment ASAM Patient Placement Criteria 2R:
Date: 8/21/2006
Six Dimensions
I.
Acute Intoxication and/or Withdrawal Potential
II.
Biomedical Conditions & Complications
III.
Emotional / Behavioral or Cognitive Conditions & Complications
IV.
Readiness to Change
V.
Relapse, Continued Use or Continued Problem Potential
VI.
Recovery / Living Environment
Level of Care:
Comment:
Severity
Medium
Low
High
Medium
Low
High
Stage of Change
Preparation
Comment
Comment
Diagnosis
Axis I
300.02
Axis II
V71.09
No Diagnosis
Axis III
Axis IV
Axis V
Treatment Techniques
Treatment Modalities:
CPT Code
90806
Type
Indiv. OP Psychotherapy-45" no Med. Eval
Recommended
Level of care
Outpatient
Least Restrictive
Alternative?
Yes
Frequency
1 Weekly
Agreement with
level of care?
Yes
Provider
Default Provider
Is recommended level
of care available?
Yes
Modality Note:
Treatment Approaches:
The following treatment approaches are being implemented: Cognitive Restructuring, Behavioral Techniques
Date:
Dosage
5mg.
ID: 1
Page #: 4
SSN: 555-55-5555
End Date
Birthday: 7/7/1946
Date:
Prescribed by Note
Dr.Jones
Presenting Problems
Primary Anxiety
Secondary Chronic Pain
Treatment Plan
Primary Problem:
Behavioral Definition
Anxiety
Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a
number of events or activities.
Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying
asleep, exhibiting a general state of irritability).
Long-term Goals
Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.
Short-Term Objectives
Therapeutic Interventions
Target Date:
Critical? No
Target Date:
Critical? No
Target Date:
Critical? No
Provider:
Provider:
Provider:
ID: 1
Page #: 5
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Sanderson).
Entry Date: 8/7/2006
Target Date:
Critical? No
Identify, challenge, and replace biased, fearful selftalk with positive, realistic, and empowering self-talk.
Entry Date: 8/7/2006
Projected Sessions:
Target Date:
Critical? No
Target Date:
Critical? No
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
ID: 1
Page #: 6
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Secondary Problem:
Behavioral Definition
Target Date:
Critical? No
Provider:
Provider:
Chronic Pain
Has decreased or stopped activities such as work, household chores, socializing, exercise, sex, or other pleasurable
activities because of pain.
Makes statements like "I can't do what I used to"; "No one understands me"; "Why me?"; "When will this go away?"; "I
can't take this pain anymore"; and "I can't go on."
Complains of generalized pain in many joints, muscles, and bones that debilitates normal functioning.
Long-term Goals
Regulate pain in order to maximize daily functioning and return to productive employment.
Short-Term Objectives
Therapeutic Interventions
Target Date:
Critical? No
Target Date:
Critical? No
Target Date:
Critical? No
Target Date:
Critical? No
Target Date:
Critical? No
Provider:
Provider:
Provider:
Provider:
Provider:
ID: 1
Page #: 7
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Target Date:
Critical? No
Target Date:
Critical? No
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Provider:
Response to Plan
Response to treatment plan presentation:
Significant Other response to treatment plan presentation:
I, Judy A. Sample, have reviewed this treatment plan.
x. _______________________________________________
Date: ______________________________
Progress Notes
Session 1
Date: 8/7/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy
(60 min)
Psychotherapy Note:
Judy has shared her symptoms of anxiety. She experinces worry surrounding her safety but cannot explain why she should feel
ID: 1
Page #: 8
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
so threatened. She is afraid to make many decisons as she fears some dire consequence. She is tense and feels nauseous often.
Provider Signature:
1/26/2016
Date
Default Provider
Session 2
Date: 8/14/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy
(60 min)
Progress Rating:
CPT Code:
Interventions Implemented
The client was taught about how anxious fears are maintained
by a cycle of unwarranted fear and avoidance that precludes
positive, corrective experiences with the feared object or
situation.
A discussion was held about how treatment targets worry,
anxiety symptoms, and avoidance to help the client manage
worry effectively.
Interventions Implemented
A history of the client's experience of chronic pain and her
associated medical conditions was gathered.
The changes in the client's social, vocational, familial, and
intimate life that have occurred in reaction to her pain were
explored.
Psychotherapy Note:
Provider Signature:
1/26/2016
Date
Default Provider
Session 3
Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy
(30 min)
Psychotherapy Note:
Provider Signature:
Default Provider
1/26/2016
Date
Objective Ratings
Objectives Identified
Describe current and past experiences with the worry and anxiety symptoms, complete
with their impact on functioning and attempts to resolve it.
Verbalize an understanding of the cognitive, physiological, and behavioral components
of anxiety and its treatment.
Learn and implement calming skills to reduce overall anxiety and manage anxiety
symptoms.
Verbalize an understanding of the role that cognitive biases play in excessive irrational
worry and persistent anxiety symptoms.
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and
empowering self-talk.
Undergo gradual repeated imaginal exposure to the feared negative consequences
predicted by worries and develop alternative reality-based predictions.
Critical?
No
First Progress
Rating:
8/7/2006
No Change
Last Progress
Rating:
8/23/2006
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
Birthday: 7/7/1946
Date:
No
No Change
No Change
Describe the nature of, history of, impact of, and understood causes of chronic pain.
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
No
No Change
No Change
Learn and implement somatic skills such as relaxation and/or biofeedback to reduce pain No
level.
Identify negative pain-related thoughts and replace them with more positive copingNo
related thoughts.
Integrate and implement new mental, somatic, and behavioral ways of managing pain.
No
No Change
No Change
No Change
No Change
No Change
No Change
Prognosis
Prognosis Rating of successful
achievement of Goals
Good
% of Critical Objectives
Achieved by Treatment End
70%
Judy is strongly motivated to work on her issues and she has a good support network.
Discharge
Discharge Criteria:
Mood, behavior and thought stabilized sufficiently to independently carry out basic self-care.
Verbalizes names of supportive resources who can be contacted if feeling suicidal/homicidal.
Hallucinations or delusions controlled enough to not interfere with basic self-care.
Competent
Competent
Outpatient Therapy
Self Care
Return to full-time job
Provider Credentials
Primary Treatment Provider
Default Provider
Supervisor
Default Provider
License:
License:
______________________________________________
Treatment Team: Clinical Staff
Default Provider
ID: 1
Page #: 10
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Requested Amendments
Request Date: 8/7/2006
Section: Progress
Reason for Denial:
Person Approving/Denying: Jongsma, Arthur E (PhD)
Amendment:
Approved: Yes
Person Requesting:
Judy wants to point out that she has always been tense and fearful.
Disclosure Authorizations
Patient was provided PHI Privacy Notice: Yes
Patient signed PHI Privacy Acknowledgement: Yes
Patient Has Not Signed but Receipt of Form was Witnessed: No
Date: 8/7/2006
Authorization on File:
Address:
General Notes
Yes
To Whom:
Bill Allen
City: Fastoo