Provider Name: Dr. Emily Carter
Date: 1 November 2024
People present: Dr. Emily Carter, John Doe (client), Jane Doe (mother)
Clientβs Clinical Status: At the beginning of the session, John appeared anxious and was exhibiting repetitive hand movements. He was non-verbal and required prompting to engage in activities.
Activities/Services Client Participated in: John participated in a series of structured play activities designed to improve his social interaction skills. He engaged in turn-taking games and was encouraged to make eye contact during interactions.
Goals Worked On: The session focused on enhancing John's communication skills, specifically increasing his use of gestures to express needs and improving his ability to follow simple instructions.
Summary of Behaviors Observed: During the session, John initially resisted participation but gradually became more engaged. He responded positively to verbal praise and showed increased eye contact. However, he occasionally reverted to hand-flapping when frustrated.
Summary of Techniques Used: The session utilized positive reinforcement and modeling techniques to encourage desired behaviors. Visual aids were also employed to help John understand the sequence of activities.
Additional Information: John's mother reported that he had a restless night and was more irritable than usual. She also mentioned a recent change in his diet, which might be affecting his behavior.
Provider Name: [insert provider name] (only include provider name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date: [insert date of session] (only include date if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
People present: [list the individuals present during the session] (write as a single line or brief list separated by commas; include only if people present have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Clientβs Clinical Status: [describe the clientβs status prior to or at the beginning of the session] (write as a short paragraph using objective clinical language; include only if client status has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Activities/Services Client Participated in: [describe the activities or services the client participated in during the session] (write as full sentences in paragraph format; include only if session activities or services have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Goals Worked On: [identify the behavior goals or skill targets that were addressed in the session] (write in full sentences using measurable, objective language; include only if goals worked on have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Summary of Behaviors Observed: [summarise the clientβs behavior during the session] (write as a paragraph in full sentences; cover antecedents, behaviors, consequences, and patterns observed if mentioned; include only if behaviors observed have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Summary of Techniques Used: [summarise the ABA techniques and interventions used during the session] (write in paragraph format using full sentences; include only if techniques used have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional Information: [include any other relevant notes or contextual factors influencing the session] (write in full sentences or short paragraph; may include information about routine changes, sleep, food, environment, caregiver input etc.; include only if additional information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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.)