General Practitioner-Vorlage
DBT session note
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a structured way to document Dialectical Behaviour Therapy (DBT) sessions? This DBT session note template is designed for General Practitioners and other mental health professionals. It helps you capture crucial details like life-threatening behaviours, therapy-interfering behaviours, and quality-of-life issues. The template guides you through reviewing diary cards, assessing risk, and outlining interventions and homework. This template ensures comprehensive documentation, making it easier to track progress and tailor treatment plans. It's a valuable tool for any clinician providing DBT, helping to streamline the note-taking process and improve patient care.
Vorlagenvorschau
## DBT session note
1. Diary Card Review-
Life Threatening Behaviours- The client reported suicidal ideation on 2 days out of the week.
Therapy Interfering Behaviours- The client arrived late to the individual therapy session on 1 day out of the week.
Quality-of-Life Interfering behaviours- The client reported engaging in social isolation on 3 days out of the week.
Top targets for behaviour change-
* Reduce suicidal ideation (client identified).
* Improve punctuality for therapy sessions (therapist identified).
* Increase social engagement (client identified).
Solution-
* Utilize distress tolerance skills when experiencing suicidal thoughts.
* Set reminders and plan for timely arrival to sessions.
* Schedule and attend social activities.
Plan-
* Practice the STOP skill when experiencing suicidal thoughts.
* Set alarms and leave home earlier for sessions.
* Join a book club.
Urges to quit- The client expressed frustration with the intensity of the DBT program and considered quitting due to the emotional challenges it presented.
Effectiveness- The client reported using the DEAR MAN skill to communicate needs to a friend on 1 day out of the week. The therapist noted the client used the skills successfully.
2. Review of modes of treatment-
* [x] Individual therapy sessions
* [x] Group skills training session
* [x] Coaching calls in an appropriate manner
3. Intervention- The client presented with suicidal ideation and social isolation. The therapist utilized distress tolerance skills to manage suicidal thoughts and encouraged the client to engage in social activities. The client was late to the session and the therapist discussed the importance of punctuality.
4. Risk- The client presents with a moderate risk of self-harm due to suicidal ideation. Safety plan reviewed and updated. Client agreed to contact crisis services if needed.
5. Plan-
* Homework: Complete diary card daily.
* Next session: Continue working on distress tolerance skills and explore barriers to social engagement.
Date: 1 November 2024
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