Behaviour Therapy Note

SUBJECTIVE: Chief Complaint: pt. presented with: anxiety and difficulty managing stress TOPIC/THEME DISCUSSED: Coping mechanisms for anxiety, stress management techniques SYMPTOMS AND SIGNS OF DISTRESS: Increased heart rate, restlessness, difficulty concentrating AREAS OF IMPAIRMENT: Work performance, social interactions ISSUES/STRESSORS: "I feel overwhelmed at work and can't focus on tasks." TARGET PROBLEMS: Anxiety management, stress reduction TREATMENT OBJECTIVES: Improve coping skills, enhance focus and productivity History Of Present Illness: Patient has a history of generalized anxiety disorder, exacerbated by recent job changes and increased workload. Social History: Suicide/Violence Risk: denies Danger to Others: denies Child Abuse: denies Safety Plan: call therapist, talk to someone, call 911 Current Medications: Name of Medication: Sertraline Dosage: 50mg Review of System: Nervous system: reports increased anxiety, Cardiovascular: increased heart rate OBJECTIVE: Objective Notes: Mental status is within normal limits unless otherwise specified Strengths: Patient demonstrates strong problem-solving skills and a supportive social network ASSESSMENT: Diagnosis: ICD-10 Codes: F41.1 Generalized Anxiety Disorder Diagnostic Assessments: No new diagnoses noted PLAN: Procedures: Cognitive Behavioral Therapy, Relaxation techniques, Coping Skills development Procedure Notes: Cognitive Behavioral Therapy to address anxiety, focus on relaxation techniques Goal: Reduce anxiety symptoms, improve stress management Care Plan: Regular therapy sessions, practice relaxation techniques, engage in physical activity response to treatment: TREATMENT COMPLIANCE: compliant RESPONSE TO TREATMENT: positive transferred from Heidi