Concerns:
Mrs. Jones, a 45-year-old female, expressed her primary concern as a recent diagnosis of pre-diabetes. She demonstrated a moderate level of self-awareness, acknowledging the need for lifestyle changes but also expressing some anxiety about the implications of the diagnosis and the changes required.
Elements of concern:
Mrs. Jones identified several factors contributing to her concern. These included her dietary habits, specifically a high intake of processed foods and sugary drinks. She also mentioned a sedentary lifestyle, with limited physical activity due to her desk job and lack of motivation. Additionally, she cited stress related to her work and family responsibilities as a contributing factor.
Context:
Mrs. Jones lives with her husband and two teenage children. She works full-time in an office setting. Her family history includes diabetes in her father, which she recognises as a risk factor. She reports a supportive relationship with her husband, but struggles to find time for herself due to her busy schedule.
Extended context:
- Mood: Generally positive, but with moments of anxiety related to her health.
- Sleep: Reports sleeping 7-8 hours per night, but often feels tired during the day.
- Employment/Education: Works full-time as an office manager.
- Family: Supportive husband and two teenage children.
- Social: Active in a book club.
- Exercise/Physical Activity: Limited exercise, primarily walking.
- Eating Regime/Appetite: High intake of processed foods and sugary drinks.
- Energy Levels: Fluctuating energy levels, often feeling tired in the afternoon.
- Recreational/Interests: Enjoys reading and spending time with family.
Concern revisited:
After discussing the extended context, Mrs. Jones reaffirmed her primary concern about pre-diabetes. She acknowledged the need to address her diet and physical activity levels, and also recognised the impact of stress on her health.
Desired state:
Mrs. Jones expressed a desire to improve her overall health and well-being, specifically aiming to manage her blood sugar levels and reduce her risk of developing type 2 diabetes. She also wants to feel more energetic and less stressed.
Hindrances:
Mrs. Jones identified several hindrances. These included a lack of time due to her busy schedule, a preference for convenience foods, and a lack of motivation to exercise. She also mentioned the emotional impact of her diagnosis and the challenges of changing long-standing habits.
Readiness:
Mrs. Jones expressed a moderate level of readiness to make changes. She acknowledged the importance of addressing her pre-diabetes and expressed a willingness to try new strategies. She stated, "I know I need to do this for my health, and I'm ready to give it a try."
Transtheoretical Model of Change:
- Contemplation: Client is aware of the issue and its consequences and is considering making a change in the future.
Education:
We discussed the importance of a balanced diet, regular physical activity, and stress management techniques. I provided information on portion control, reading food labels, and incorporating exercise into her daily routine. We also discussed the benefits of stress-reduction techniques such as mindfulness and deep breathing exercises. Further education on carbohydrate counting and meal planning was recommended.
Modalities:
Motivational Interviewing (MI)
• Open-ended questions were used to explore Mrs. Jones's motivation, and she responded by sharing her concerns and expressing her desire to improve her health.
• Reflective listening was employed to validate her responses, and she appreciated the opportunity to be heard.
• Change talk was elicited, and Mrs. Jones expressed her willingness to make changes.
• Client autonomy and collaboration were emphasised, and Mrs. Jones felt empowered to take control of her health.
Integrative Health Coaching (IHC)
• Vision development of the client’s best self was discussed, and Mrs. Jones envisioned herself as healthy, energetic, and able to enjoy life to the fullest.
• The Wheel of Health was explored, and the Whole-person assessment revealed areas for improvement in nutrition, exercise, and stress management.
• Goals aligned with personal values were identified and discussed, with Mrs. Jones prioritising her health and well-being.
• Action steps were developed, including meal planning, incorporating exercise into her routine, and practicing stress-reduction techniques.
Goals and/or plans:
We developed specific goals and plans to support Mrs. Jones's progress. These included setting a goal to walk for 30 minutes, three times a week, and to reduce her intake of sugary drinks. We also discussed the importance of meal planning and incorporating more fruits and vegetables into her diet.
SMART outcomes:
• Specific goals included walking for 30 minutes, three times a week, and reducing sugary drinks.
• Goals were considered actionable, and Mrs. Jones felt confident in her ability to achieve them.
• Goals were realistic, considering her current lifestyle and available time.
• The timeline for implementation was immediate, starting this week.
• Effectiveness will be measured by tracking her blood sugar levels and monitoring her progress.
Value alignment:
Mrs. Jones identified her values as health, family, and well-being. These values align with the goals and plans developed, as they support her desire to improve her health and spend more quality time with her family.
Worthiness:
Mrs. Jones expressed a sense of self-worth and value, recognising the importance of taking care of herself as a foundation for change. She stated, "I deserve to be healthy and happy."
GP and medical interactions:
Mrs. Jones is scheduled to see her GP next week for a follow-up on her pre-diabetes diagnosis. I advised her to discuss her progress and any concerns she may have with her GP. I also suggested she share the goals and plans we developed during our session. Further research on the latest guidelines for pre-diabetes management was recommended.
Coach assessment:
The session followed a coach-centric empowering model, with an emphasis on collaboration and client autonomy. Mrs. Jones actively participated in the session and expressed a sense of empowerment.
Follow-up:
• Obstacles discussed included lack of time and temptation of unhealthy foods. Mrs. Jones can anticipate these by planning her meals and scheduling exercise.
• Supports discussed included family support and the use of a fitness app.
• Mrs. Jones's efforts were emphasised and validated, and she was encouraged to celebrate small victories.
• Mrs. Jones was encouraged to try new approaches and tolerate failure.
• Supports discussed included relationships, sleep, nutrition, movement, and meaning making.
Next session scheduled for 15 November 2024.
Concerns:
[Describe the main concern or health priority identified by the client and comment on the client’s level of self-awareness regarding this concern or priority] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Elements of concern:
[Detail the various factors or themes that affect or contribute to the client’s concern] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Context:
[Describe the overall life context in which the client is situated, including relevant circumstances, life situation, or contextual elements that may influence the concern or impact outcomes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Extended context:
- Mood: [Describe current mood] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Sleep: [Detail sleep patterns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Employment/Education: [Describe current employment or educational status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Family: [Detail family dynamics and relationships] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Social: [Describe social interactions and support network] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Exercise/Physical Activity: [Detail exercise routines or physical activities] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Eating Regime/Appetite: [Describe eating habits and appetite] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Energy Levels: [Detail energy levels throughout the day] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Recreational/Interests: [Mention hobbies or interests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Concern revisited:
[Describe if the main concern changed after discussing the extended context, and whether anything was reaffirmed or newly identified] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Desired state:
[Summarise what the client identified as their desired state and whether any comparisons were drawn between the desired state and the current situation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Hindrances:
[Identify internal and external hindrances as perceived by the client that may obstruct resolution of the concern or achievement of their goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Readiness:
[Comment on the client’s readiness to make changes in relation to their concern, hindrances and context, and include the language they used to describe their motivation and perceived readiness] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Transtheoretical Model of Change:
[Identify the stage of change the client is currently in and provide reasoning or insights shared by the client that support this stage classification] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as a single selection from the following bullet points.)
- Pre-contemplation: [Client is not yet considering behaviour change or does not view the behaviour as a significant concern] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Contemplation: [Client is aware of the issue and its consequences and is considering making a change in the future] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Preparation: [Client is actively preparing and planning to make a behavioural change] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Action: [Client is currently engaged in changing the behaviour] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
- Maintenance: [Client is actively working to maintain their new behaviour and prevent relapse] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Education:
[Detail the areas of health literacy or education discussed with the client, and identify any outstanding educational needs relevant to the client’s concern or goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Modalities:
(Only include this section if explicitly mentioned in transcript or context, else omit section entirely.)
Motivational Interviewing (MI)
• [Were open-ended questions used to explore client motivation and how did the client respond?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Was reflective listening employed to validate client responses?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Was change talk elicited and how did the client respond?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Was client autonomy and collaboration emphasised and how did the client respond?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Integrative Health Coaching (IHC)
• [Was vision development of the client’s best self discussed?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Was the Wheel of Health explored and what emerged from the Whole-person assessment?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Were goals aligned with personal values identified and discussed?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Were action steps developed and how were they articulated?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Functional Imagery Training (FIT)
• [How confident was the client in using imagination to support behavioural change?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [What issue was discussed and what negative imagery was visualised?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [How did the client respond to negative imagery, emotionally or physically?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [What positive imagery was visualised and what did it represent?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [How did the client respond to positive imagery, emotionally or physically?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Goals and/or plans:
[Describe the specific goals or plans developed to support the client’s progress, and note the client's perceived importance or confidence in achieving them] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
SMART outcomes:
• [What specific goals or plans were discussed?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Were the goals or plans considered actionable, and how was this discussed?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [Were the goals or plans realistic, and what discussion supported this?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [What is the timeline for implementation of the goals or plans?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [How will the goals or plans be measured for effectiveness?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
Value alignment:
[Summarise the values and sense of purpose identified by the client and reflect on how these values align with the goals or plans developed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Worthiness:
[Comment on how the client expressed or failed to express a sense of self-worth, value, or belief in their own importance as a foundation for change] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
GP and medical interactions:
[Summarise any discussions about medical concerns, medications, GP visits or non-coaching issues; include what should be followed up with or discussed with the GP by the coach or client, and any further research needs] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Coach assessment:
[Reflect on the style of the session—whether it followed an expert model or a coach-centric empowering model—and summarise how this manifested in the interaction] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Follow-up:
• [What obstacles were discussed and how can the client anticipate or be proactive against them?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [What supports could assist the client in problem-solving or normalising experimentation?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [How were the client's efforts—rather than outcomes—emphasised and validated?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [How was the client’s creativity in trying new approaches or tolerating failure encouraged?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
• [What supports were discussed that may facilitate progress, especially in areas like relationships, sleep, nutrition, movement, and meaning making?] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in brief bullet points.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
