Psychotherapy Note for Eating Disorders

Start and stop time: [please note length of recording] Subjective: - [describe reported symptoms, patient synopsis of their most recent week, things they achieved, things they struggled with, and what was specifically targeted during the session. Never use bullet points to write the subjective section below. Use full sentences and paragraph format to capture the information in the subjective section.] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Please try to be concise and avoid redundancy in narrative description. ) Origin of reported symptoms: - [describe origin of reported symptoms] (only include describe origin of targeted symptoms if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Interventions used: Affective interventions: - [describe any interventions used that appear to be intended to explore and better understand mood.] (only include describe affective interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Cognitive interventions: - [describe any interventions that originate in a cognitive behavioral therapy framework. State the official name for the intervention used.] (only include describe cognitive interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Mind-body interventions: - [describe any interventions that target mindfulness, relaxation, or behavioral activation] (only include describe mind-body interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Motivational and values-based interventions: - [describe interventions targeting motivation and/or acting in accordance with the client's personal values] (only include describe motivational interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) ACT informed interventions: - [describe any interventions that originate in an acceptance and commitment therapy framework.] (only include describe ACT informed interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) DBT informed interventions: - [describe DBT informed interventions] (only include describe DBT informed interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Interventions focused on sense of self/identity: -[describe interventions used to facilitate more positive self-esteem and increased understanding of identity.] (only include describe motivational interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) MANTRA Interventions: -[describe any interventions that are used as part of Maudsley Anorexia Nervosa Treatment for Adults] (only include describe motivational interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) CBT-E Interventions: -[describe any interventions that are used as part of Cognitive Behavioral Therapy enhanced for Eating Disorders.] (only include describe motivational interventions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Objective: - [describe objective findings. Please include a mental status exam. Include appearance, speech patterns, stated or observed mood, judgment, insight level, cognition.] (If not able to determined, or explicitly mentioned, assume "within normal limits." If unable to determine speech patterns or quality, assume "normal in rhythm and rate.") Overall assessment: - [Never use bullet points to write the assessment section below. Use full sentences and paragraph format to capture the information in the subjective section. Indicate how the client seemed to respond to interventions.] (only include provide overall assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Homework from previous session addressed: - [describe homework from previous session] (only include describe homework from previous session if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Homework assigned this session: - [describe homework assigned this session] (only include describe homework assigned this session if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Plan for next session: - [describe plan for next session] (only include describe plan for next session if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Risk assessment: - [describe risk assessment] (only include describe risk assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Medical necessity: - [summarize why a longer session was appropriate for the utilized interventions, based on context of transcript, as opposed to the traditional 50 minute session.] (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 the patient's name is not mentioned in the transcript, default to calling the patient "the patient." Do not include names of friends, family, or supportive others mentioned by patient in the transcript, but use generic language instead. 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.)