Substance Abuse Group Therapy Note Sample
Alcohol Dependence, 303.90 (Active) Encouraged to actively participate in group process. Encour aged to attend at least three sessions a week. NOTES & RISK FACTORS : History of Subst. Abuse Has been self -injurious Time spent counseling and coordinating care: 55 -70 min Session start: 10:00 AM Session end: 10:55 AM Mary Jones, LAC
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Mental Status Exam Checklist - ICANotes
www.icanotes.comPerception Is your client experiencing: No hallucinations Auditory hallucinations Visual hallucinations Tactile hallucinations Derealization Depersonalization Olfactory hallucinations Illusions 5. Thought and Perception Thought Process Would you describe your client's thought process as: Suicidal ideation Homicidal ideation Distortions
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www.icanotes.comNote: This Progress Note was created in ICANotes in 2 minutes. Only two sentences were typed, those highlighted in yellow. The rest of the content was generated by clicking buttons to generate personalized narrative text.
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www.icanotes.comThis group therapy note was created in the ICANotes Behavioral Health EH R . All narrative was generated through menu -driven templates. The only words typed are highlighted in yellow.
PSYCHIATRIC OUTPATIENT CLINIC Time of Exam: 5:22:37 PM
www.icanotes.comPrior Depressive /Manic Episodes: She repor ts that there have been no prior depressive episodes. Mrs. Little does not have a history of manic or hypomanic episodes. Severity/ Complexity: Based on the risk of morbidity without treatment and her description of interference with functioning, se verity is estimated to be moderate.
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www.icanotes.comThe following pattern of use is described: *Alcohol is often taken in larger amounts or over a longer period than was intended. *There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. *A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Outpatient Treatment Plan - ICANotes
www.icanotes.comSNAP : Golden, Mary has identified the following strengths, needs, abilities and preferences as well as goals and desired accomplishments. This information will be used in the development of the patient's personal achievement agenda. Strengths: *A stable environment *Supportive spiritual beliefs. Needs: *An explanation of my diagnoses.
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www.icanotes.comTime spent counseling and coordinating care: 45 -50 min Session start: 2:00 PM Session end: 2:50 PM Liz Lobao, MD Electronically Signed By: Liz Lobao, RN On: 3/1 6/2012 3:22 :34 PM. Title: Mental Health Progress Note Sample Author: …
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www.icanotes.comInstructions / Recommendations / Plan: The risks and benefits of Psychotropic medications were explained to Anna. Cognitive Therapy Relaxation Techniques Start Paxil 10 mg PO QAM (Anxiety) Start Buspirone 10 mg PO QAM (Anxiety) Start Ambien CR 6.25 mg PO QHS (Insomnia) Continue Synthroid 50 mcg PO QAM (Hypothyroidism) ...
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www.icanotes.comThis sample SO AP note was created using the ICANotes Behavioral Health EHR. The only words typed by the clinician are highlighted in yellow . Visit http s://www.ICANotes.com for a free trial or demo. October Boyles, LPC 123 Main Street, Suite 202 Anywhere, US 1234 5 Tel: 555 -678 -9100 Fax: 555 -678 -9111 1/30/2019 9: 50 :04 AM
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