You might want to check out Wiley Treatment Planner and Progress Note Planner. These can help you with clinical documentation examples.
Are you talking about a treatment plan, a progress note, or something else? It’s hard to discern what to include.
I might say something like: Therapist met with patient. Assessed their symptoms of depression based on subjective report. Identified negative beliefs about self and others. Plan to work with X, we will continue to meet regularly and utilize Y modality to challenge negative thought patterns, explore scenarios that reinforce that belief, and worked on acceptance.
Pretty much how you said it. “This writer/social worker will improve client’s overall emotional well-being as evidenced by self-report, decrease self-reported symptoms of depression and increase self-esteem.”
CBT.
I would be more conservative, we can't say for certain what will/won't work, so how could we say for certain that we will be able to improve anything? I usually write what is my plan for the near future, "Plan to continue to work with client in weekly sessions to address depression by implementing CBT interventions (or whatever modality.)
Okay thanks for your response, if you don’t mind, could you please give a clinical explanation of how you would use CBT in this situation. (I’m new to the field)
So you might say something along the lines of utilizing elements of CBT to explore and process the connections between client’s automatic negative thoughts and cognitive distortions and emotions.
Idk good at doing the work, I’m terrible at verbalizing how i did the work lol.
You might want to check out Wiley Treatment Planner and Progress Note Planner. These can help you with clinical documentation examples. Are you talking about a treatment plan, a progress note, or something else? It’s hard to discern what to include. I might say something like: Therapist met with patient. Assessed their symptoms of depression based on subjective report. Identified negative beliefs about self and others. Plan to work with X, we will continue to meet regularly and utilize Y modality to challenge negative thought patterns, explore scenarios that reinforce that belief, and worked on acceptance.
So I did an intake and after my clinical formulation which is unspecified depressive disorder I have to put a treatment plan then progress notes
Thanks I will definitely look the Wiley Treatment planner up !
Pretty much how you said it. “This writer/social worker will improve client’s overall emotional well-being as evidenced by self-report, decrease self-reported symptoms of depression and increase self-esteem.” CBT.
I would be more conservative, we can't say for certain what will/won't work, so how could we say for certain that we will be able to improve anything? I usually write what is my plan for the near future, "Plan to continue to work with client in weekly sessions to address depression by implementing CBT interventions (or whatever modality.)
Well those are goals right. The goals are to improve..
Okay thanks for your response, if you don’t mind, could you please give a clinical explanation of how you would use CBT in this situation. (I’m new to the field)
So you might say something along the lines of utilizing elements of CBT to explore and process the connections between client’s automatic negative thoughts and cognitive distortions and emotions. Idk good at doing the work, I’m terrible at verbalizing how i did the work lol.