Behavior:
- The patient presented with a depressed mood and flat affect. They exhibited signs of anxiety, including fidgeting and avoiding eye contact.
Intervention:
- Cognitive-behavioral therapy techniques were employed to address the patient's negative thought patterns. Additionally, relaxation exercises were introduced to help manage anxiety symptoms.
Response:
- The patient showed slight improvement in mood and was able to engage more actively in the session. They reported feeling somewhat relieved after the relaxation exercises.
Plan:
- Continue with weekly therapy sessions focusing on cognitive-behavioral techniques. A referral to a psychiatrist for medication evaluation was made. Follow-up appointment scheduled for next week.
Behavior:
- [describe patient's behavior, including mood, affect, and any observed behaviors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Intervention:
- [describe interventions provided during the session, including therapeutic techniques, medications administered, and any other treatments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Response:
- [describe patient's response to the interventions, including any changes in symptoms, mood, or behavior] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [outline the plan for future treatment, including follow-up appointments, referrals, and any changes to the treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(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 section blank.)(Use as many full sentences as needed to capture all the relevant information from the transcript.)
