Client: Sarah Jones
Date: 1 November 2024
Worker: Dr. Emily Carter
**MSE:**
Appears her age, well-groomed, cooperative, normal speech, congruent mood, appropriate affect, linear thought process, no active suicidal ideation, intact cognition, good insight, low risk.
**Presenting Issue:**
- Reports feeling overwhelmed by work and family responsibilities.
- History of anxiety and occasional panic attacks.
- Seeking strategies to manage stress and improve coping mechanisms.
**Focus/Support:**
- Explored the client's current stressors and triggers.
- Discussed relaxation techniques and mindfulness practices.
- Provided psychoeducation on anxiety management.
**Next Step:**
- Schedule a follow-up session next week.
- Client to practice relaxation techniques daily.
- Client to consider joining a support group.
**PTMF:**
Power:
- Feeling of being controlled by external demands.
- Lack of control over work environment.
Threat:
- Financial pressures.
- Fear of failure.
Meaning:
- Believes she must always be productive.
- Sees herself as responsible for everyone's happiness.
Response:
- Avoidance of difficult situations.
- Increased irritability.
Strengths:
- Strong support network.
- Resilience in the face of adversity.
Story:
Sarah's narrative centres on a lifelong pattern of over-achievement and people-pleasing, leading to chronic stress and anxiety. She is beginning to recognise the impact of these patterns and is motivated to make changes.
**Outcome:**
Sarah engaged actively in the session, expressing a willingness to explore new coping strategies. She appeared relieved to have a space to discuss her challenges and left feeling hopeful about the future.
Client: [client's name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as text.)
Date: [date of consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as text.)
Worker: [worker's name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as text.)
**MSE:**
[description of mental state examination findings including appearance, behaviour, speech, mood, affect, thought process, thought content, perception, cognition, insight, and risk assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise phrase with forward slashes as delimiters.)
**Presenting Issue:**
[description of the presenting issue including the client's current concerns, history, and relevant background information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Focus/Support:**
[description of the key areas of focus during the session and the support provided, including therapeutic interventions, counselling, or specific discussions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Next Step:**
[description of the agreed-upon next steps including future appointments, referrals, or actions to be taken by the client or worker] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**PTMF:**
Power:
[description of power dynamics and influences relevant to the client's situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
Threat:
[description of perceived threats or vulnerabilities impacting the client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
Meaning:
[description of the meaning the client attributes to their experiences and challenges] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
Response:
[description of the client's responses and coping mechanisms to their situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
Strengths:
[description of the client's identified strengths and resources] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
Story:
[summary of the client's narrative, including their journey, insights, and future aspirations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief concise paragraph.)
**Outcome:**
[description of the immediate outcome of the session, including the client's engagement, receptiveness, and overall state upon completion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
(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 included 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. Limit size of note to 300 words)
