Psychology Session Notes

(The template or structure below is intended to be used for a follow up session or progress note by clinical psychologists. It is important that you note that the details of the topics discussed in the transcript may vary greatly between patients, as a large proportion of the information intended for placeholders in square brackets in the template or structure below may already be known and well established in the context of the relationship between the clinicial psyc hologist and the patient. If there is no specific mention in the transcript or contextual notes of the relevant information for a placeholder below, you should not include the placeholder in the clinical note or document that you output - instead you should leave it blank. Do not hallucinate or make up any information for a placeholder in the template or structure below if it is not mentioned or present in the transcript. The topics discussed in the transcript by clinical psychologists are sometimes not well-defined clinical disease states or symptoms and are often just aspects of the patient's life that are important to them and they wish to discuss with their clinician. Therefore it is vital that the entire transcript is used and included in the clinical note or document that you output, as even brief topic discussions may be an important part of the patient's mental health care. The placeholders below should therefore be used as a guide to how the information in the transcript should be captured in the clinical note or document, but you should interpret the topics discussed and then use your judgement to either: exclude sections from the template or structure below because it is not relevant to the clinical note or document based on the details of the topics discussed in the transcript, or include new sections that are not currently present in the template or structure, in order to accurately capture the details of the topics discussed in the transcript. Remember to use as many bullet points as you need to capture the relevant details from the transcript for each section. Use the word Client instead of Patient. Do not respond to these guidelines in your output; you must only output the clinical note or document as instructed.) OUT OF SESSION TASK REVIEW: - [Detail the patient's practice of skills, strategies or reflection from the last session]. (use as many bullet points as needed to capture all the details of the patient’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail the patient's report on the completion and effectiveness of these tasks]. (use as many bullet points as needed to capture all the details of the patient’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail any challenges or obstacles faced by the patient in completing these tasks?]. (use as many bullet points as needed to capture all the details of the patient’s practice of skills, strategies, reflections on the last session and any issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) CURRENT PRESENTATION: - [Detail the patient’s current presentation, including symptoms and any new arising issues]. (use as many bullet points as needed to capture all the details of the patient’s symptoms and issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail any changes in symptoms or behaviors since the last session]. (use as many bullet points as needed to capture all the details of the patient’s symptoms and issues; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) SESSION CONTENT: - [Describe any issues raised by the patient.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Describe details of relevant discussions with patient during the session.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Describe the therapy goals/objectives discussed with patient.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Describe the progress achieved by patient towards each therapy goal/objective.]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail the main topics discussed during the session, any insights or realisations by the patient, and the patient's response to the discussion]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) INTERVENTION: - [Detail the specific therapeutic techniques and interventions used or to be used, for example, CBT, Mindfulness Based CBT, ACT, DBT, Schema Therapy, or EMDR.] (use as many bullet points as needed to capture all the details discussed. ) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) [Destail the specific techniques or strategies used and the patient's engagement with the interventions.]. (use as many bullet points as needed to capture all the details discussed. ) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) SETBACKS/ BARRIERS/ PROGRESS WITH TREATMENT - [Describe the setbacks, barriers, obstacles, or progress for each therapy goal/objective]. (use as many bullet points as needed to capture all the details discussed; only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail the client’s comments on their satisfaction with treatment]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank).] RISK ASSESSMENT AND MANAGEMENT: - Suicidal Ideation: [describe any history of suicidal ideation, attempts, plans in detail]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Homicidal Ideation: [Describe any homicidal ideation]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Self-harm: [Detail any history of self-harm]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - Violence & Aggression: [Describe any recent or past incidents of violence or aggression]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Management Plan: [Describe strategy or steps taken to manage suicidal ideation / homicidal ideation / self-harm / violence & aggression (if applicable)]. (use as many bullet points as needed to capture all the details discussed) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) MENTAL STATUS EXAMINATION: Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Speech: [Note the rate, volume, tone, clarity, and coherence of the patient's speech]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Mood: [Record the patient's self-described emotional state]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank). OUT OF SESSION TASKS - [Detail any tasks or activities assigned to the patient to complete before the next session and the reasons for the tasks]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) PLAN FOR NEXT SESSION - Next Session: [mention date and time of next session]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Detail the specific topics or issues to be addressed at the next session, any planned interventions or techniques to be used]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) (Ensure all information discussed in the transcript is included under the relevant heading or sub-heading above, otherwise include it as a bullet-pointed additional note at the end of the note.) (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 to include in your note. Ensure the output is superdetailed and do not use quotes. 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 the word Client instead of Patient)