Clinical Hour and Patient Logs
Clinical Hour and Patient Logs
Assignment 4: Clinical Hour and Patient Logs
Assignment Instructions:
· I need 16 small individual psychotherapy clinical notes (one paragraph), each note should include: CC, small mental status, and progress achieved during the visit. Please review the below example, doesn’t have to exactly as the example but close enough.
· Student Notes- Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter
· Can be adult male or female age between 18 to 65, with any (1 or more) of the following diagnosis:
Example:
(Fem, -49 Mood Disorder, Anxiety Disorder)
49-year-old patient with depressive disorder associated to monetary problems due to the loss of one of her jobs, patient has only a part time position. Patient is here today for a follow-up consultation. The patient said, “I’m feeling better, I’m not so concerned about my late payments, since I start the financial help”. In today’s consultation session, the patient appears awake, alert, and oriented x 4. Dressed well with good hygiene and good eye contact. She presents with spontaneous speech normal rate and volume, relevant, coherent. Mood is a little anxious. Affect is mood congruent. Thought process is concrete. Thought content is linear and coherent. Patient reported that she had been performing all the activities to further decrease depression. Patient showed improvements in mood, which was the main objective to achieve this week. The patient’s mood has continually improved for the past three weeks. The symptoms of depression have decreased, as per patient’s reports crying less, and improving her sleep time. The patient was encouraged to continue with follow-up psychotherapy. Individual psychotherapy and follow up scheduled next week to continue improving the patient’s condition.
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