Name: Judy A.
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
Total Sessions Authorized This Episode:
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.
Name: Judy A. Sample
1/26/2016
Strengths/Weaknesses
Strengths:
Weaknesses:
ID: 1
Page #: 2
SSN: 555-55-5555
Birthday: 7/7/1946
Stable Work History, Positive Support Network, Motivated for Change
Poor Health, Indecisive
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
Global Severity Index
8/14/2006
Patient
11.00
Global Severity Index
9/11/2006
Patient
7.00
Treatment
Phase
Details
PreTreatment
During
Treatment
PostTreatment
Interpretation Note:
Mental Status:
Presentation
Date First Rated: 8/7/2006
Appearance:
Mood:
Attitude:
Affect:
Speech:
Motor Activity:
Orientation:
Mental Functioning
Simple Calculations:
Serial Sevens:
Immediate Memory:
Remote Memory:
General Knowledge:
Proverb Interpretation:
Similarities/Differences:
Higher Order Abilities
Judgment:
Insight:
Intelligence:
Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:
Risk Assessment
Well-Groomed
Anxious
Cooperative
Appropriate
Pressured
Tense
Fully Oriented
Date First Rated: 8/7/2006
Date Last Rated:
Accurate
Accurate
Intact
Intact
Accurate
Accurate
Accurate
Date First Rated: 8/7/2006
Date Last Rated:
Intact
Intact
High
Date First Rated: 8/7/2006
Date Last Rated:
Logical and Organized
None Evident
None Evident
Date First Rated: Date Last Rated:
8/7/2006
Suicide:
Violence:
Date Last Rated:
None
None
Latest Note:
Date:
Name: Judy A. Sample
1/26/2016
Child Abuse:
Partner Abuse:
Elder/Parent Abuse:
ID: 1
Page #: 3
None
None
None
SSN: 555-55-5555
Birthday: 7/7/1946
Most Recent Mental Status 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
Level IV, Medically-Managed Intensive Inpatient Treatment
Recovery Assessment Stage of Change:
Problem: Anxiety
Date Assessed
8/7/2006
Stage of Change
Preparation
Problem: Chronic Pain
Date Assessed
Stage of Change
8/7/2006
Pre-contemplation
Comment
Comment
Diagnosis
Axis I
300.02
Generalized Anxiety Disorder
Axis II
V71.09
No Diagnosis
Axis III
Axis IV
Axis V
Chronic Back Pain
Health
Current: 51-60 Prior: 81-90
Stress Severity Rating: Moderate
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
Treatment Approaches:
The following treatment approaches are being implemented: Cognitive Restructuring, Behavioral Techniques
Medication
Xanax
Dosage
5mg.
Frequency Start Date
1x/day
8/7/2006
End Date
Prescribed by Note
Dr.Jones
Date:
Name: Judy A. Sample
1/26/2016
ID: 1
Page #: 4
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
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
Describe current and past experiences with the worry
and anxiety symptoms, complete with their impact on
functioning and attempts to resolve it.
Assess the focus, excessiveness, and uncontrollability of
the client's worry and the type, frequency, intensity, and
duration of her anxiety symptoms (e.g., The Anxiety
Disorders Interview Schedule for the DSM-IV by DiNardo,
Brown, and Barlow).
Verbalize an understanding of the cognitive,
physiological, and behavioral components of anxiety
and its treatment.
Discuss how generalized anxiety typically involves
excessive worry about unrealistic threats, various bodily
expressions of tension, overarousal, and hypervigilance,
and avoidance of what is threatening that interact to
maintain the problem (see Mastery of Your Anxiety and
Worry - Therapist Guide by Craske, Barlow, and O'Leary).
Assign the client to read psychoeducational sections of
books or treatment manuals on worry and generalized
anxiety (e.g., Mastery of Your Anxiety and Worry - Client
Guide by Zinbarg, Craske, Barlow, and O'Leary).
Discuss how treatment targets worry, anxiety symptoms,
and avoidance to help the client manage worry effectively
and reduce overarousal and unnecessary avoidance.
Learn and implement calming skills to reduce overall
anxiety and manage anxiety symptoms.
Teach the client relaxation skills (e.g., progressive muscle
relaxation, guided imagery, slow diaphragmatic breathing)
and how to discriminate better between relaxation and
tension; teach the client how to apply these skills to her
daily life (e.g., Progressive Relaxation Training by
Bernstein and Borkovec; Treating GAD by Rygh and
Sanderson).
Assign the client homework each session in which she
practices relaxation exercises daily; review and reinforce
success while providing corrective feedback toward
improvement.
Use biofeedback techniques to facilitate the client's success
at learning relaxation skills.
Assign the client to read about progressive muscle
relaxation and other calming strategies in relevant books or
Name: Judy A. Sample
1/26/2016
ID: 1
Page #: 5
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
treatment manuals (e.g., Progressive Relaxation Training
by Bernstein and Borkovec; Mastery of Your Anxiety and
Worry - Client Guide by Zinbarg, Craske, Barlow, and
O'Leary).
Verbalize an understanding of the role that cognitive
biases play in excessive irrational worry and persistent
anxiety symptoms.
Identify, challenge, and replace biased, fearful selftalk 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.
Maintain involvement in work, family, and social
activities.
Secondary Problem:
Behavioral Definition
Assist the client in analyzing her fear by examining the
probability of the negative expectation occurring, the real
consequences of it occurring, her ability to control the
outcome, the worst possible outcome, and her ability to
accept it (see "Analyze the Probability of a Feared Event"
in Adult Psychotherapy Homework Planner, 2nd ed. by
Jongsma, and Anxiety Disorders and Phobias by Beck and
Emery).
Assigned homework for Journal and Replace SelfDefeating Thoughts
Explore the client's schema and self-talk that mediate her
fear response; challenge the biases; assist her in replacing
the distorted messages with reality-based alternatives and
positive self-talk that will increase her self-confidence in
coping with irrational fears.
Teach the client to implement a thought-stopping technique
(thinking of a stop sign and then a pleasant scene) for
worries that have been addressed but persist (or assign
"Making Use of the Thought-Stopping Technique" in Adult
Psychotherapy Homework Planner, 2nd ed. by Jongsma);
monitor and encourage the client's use of the technique in
daily life between sessions.
Assigned homework for Making Use of the ThoughtStopping Technique
Direct and assist the client in constructing a hierarchy of
two to three spheres of worry for use in exposure (e.g.,
worry about harm to others, financial difficulties,
relationship problems).
Select initial exposures that have a high likelihood of being
a success experience for the client; develop a plan for
managing the negative affect engendered by exposure;
mentally rehearse the procedure.
Assign the client a homework exercise in which she does
worry exposures and records responses (see Mastery of
Your Anxiety and Worry - Client Guide by Zinbarg,
Craske, Barlow, and O'Leary or Generalized Anxiety
Disorder by Brown, O'Leary, and Barlow); review,
reinforce success, and provide corrective feedback toward
improvement.
Support the client in following-through with work, family,
and social activities rather than escaping or avoiding them
to focus on panic.
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.
Name: Judy A. Sample
1/26/2016
ID: 1
Page #: 6
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Long-term Goals
Regulate pain in order to maximize daily functioning and return to productive employment.
Short-Term Objectives
Describe the nature of, history of, impact of, and
understood causes of chronic pain.
Therapeutic Interventions
Assess the history and current status of the client's chronic
pain.
Explore the changes in the client's mood, attitude, social,
vocational, and familial/marital roles that have occurred as
a result of the pain.
Complete a thorough medication review by a
physician who is a specialist in dealing with chronic
pain or headache conditions.
Ask the client to complete a medication review with a
specialist in chronic pain or headaches; confer with the
physician afterward about her recommendations and
process them with the client.
Participate in a cognitive behavioral group therapy for
pain management.
Form a small, closed enrollment group (4-8 clients) for
pain management (see Group Therapy for Patients with
Chronic Pain by Keefe, Beaupre, Gil, Rumble, and
Aspnes).
Identify and monitor specific pain triggers.
Teach the client self-monitoring of her symptoms; ask the
client to keep a pain journal that records time of day, where
and what she was doing, the severity, and what was done to
alleviate the pain (or assign "Pain and Stress Journal" in
Adult Psychotherapy Homework Planner, 2nd ed. by
Jongsma); process the journal with the client to increase
insight into nature of the pain, cognitive, affective, and
behavioral triggers, and the positive or negative effect of
the interventions they are currently using.
Learn and implement somatic skills such as relaxation
and/or biofeedback to reduce pain level.
Teach the client relaxation skills (e.g., progressive muscle,
guided imagery, slow diaphragmatic breathing) and how to
discriminate better between relaxation and tension; teach
the client how to apply these skills to her daily life (see
Progressive Relaxation Training by Bernstein and
Borkovec).
Identify areas in the client's life that she can implement
skills learned through relaxation or biofeedback.
Assign a homework exercise in which the client
implements somatic pain management skills and records
the result; review and process during the treatment session.
Assign the client to read about progressive muscle
relaxation and other calming strategies in relevant books or
treatment manuals (e.g., Progressive Relaxation Training
by Bernstein and Borkovec).
Identify negative pain-related thoughts and replace
them with more positive coping-related thoughts.
Explore the client's schema and self-talk that mediate her
pain response, challenging the biases; assist her in
generating thoughts that correct for the biases, facilitate
coping, and build confidence in managing pain.
Assign the client a homework exercise in which she
identifies negative pain-related self-talk and positive
alternatives (or assign "Journal and Replace Self-Defeating
Thoughts" in Adult Psychotherapy Homework Planner, 2nd
ed. by Jongsma); review and reinforce success, providing
corrective feedback toward improvement.
Assign the client to read about cognitive restructuring in
Name: Judy A. Sample
1/26/2016
ID: 1
Page #: 7
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
relevant books or treatment manuals (e.g., The Chronic
Pain Control Workbook by Catalano and Hardin).
Integrate and implement new mental, somatic, and
behavioral ways of managing pain.
Assist client in integrating learned pain management skills
(e.g., relaxation, distraction, activity scheduling) into a
progressively wider range of daily activities; record and
review.
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)
Progress Rating: Some Progress
CPT Code:
Psychotherapy Note:
Judy has shared her symptoms of anxiety. She experinces worry surrounding her safety but cannot explain why she should feel
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
Problem Addressed: Anxiety
Patient Presentation (Signs and Symptoms)
The client related that she is constantly feeling on edge, that
sleep is interrupted, and that concentration is difficult.
The client described a history of restlessness, tiredness,
muscle tension, and shaking.
The client reported the presence of symptoms such as heart
palpitations, dry mouth, tightness in the throat, and some
shortness of breath.
Problem Addressed: Chronic Pain
Patient Presentation (Signs and Symptoms)
The client has complained of pain throughout her body and in
many joints, muscles, and bones.
The client has significantly decreased or stopped activities
related to work, household chores, socialization, exercise, and
sexual pleasure because of pain.
The client made frequent pessimistic verbalizations about her
inability to control the pain or live a normal life or be
understood by others.
Psychotherapy Note:
(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.
Name: Judy A. Sample
1/26/2016
Provider Signature:
ID: 1
Page #: 8
SSN: 555-55-5555
Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy
Date:
1/26/2016
Date
Default Provider
Session 3
Birthday: 7/7/1946
Progress Rating: No Change
CPT Code:
(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.
Maintain involvement in work, family, and social activities.
Critical?
No
First Progress
Rating:
8/7/2006
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
No
No Change
No Change
Describe the nature of, history of, impact of, and understood causes of chronic pain.
No
No Change
No Change
Complete a thorough medication review by a physician who is a specialist in dealing
with chronic pain or headache conditions.
Participate in a cognitive behavioral group therapy for pain management.
No
No Change
No Change
No
No Change
No Change
Identify and monitor specific pain triggers.
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
Rationale for Prognosis Rating:
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.
Last Progress
Rating:
8/23/2006
No Change
Name: Judy A. Sample
1/26/2016
Referral Made To:
ID: 1
Page #: 9
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
After-care Plan/ Discharge Summary:
Provider Credentials
Primary Treatment Provider
Default Provider
Supervisor
Default Provider
License:
License:
______________________________________________
Treatment Team: Clinical Staff
Default Provider
Requested Amendments
Request Date: 8/7/2006
Section: Progress
Reason for Denial:
Person Approving/Denying: Jongsma, Arthur E (PhD)
Amendment:
Approved: Yes
Person Requesting:
Approve/Deny Date: 8/7/2006
Judy Sample
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
Purpose: Provision of PHI to other professionals
Authorization on File:
Address:
General Notes
Yes
To Whom:
Bill Allen
City: Fastoo
What Disclosed: All Protected Health Information except
Psychotherapy Notes
Agency: Fastoo CMH
State: MI
ZIP: 49525
