MRU Psychiatric Patient Encounter Behavioral Therapy Note

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These assignments allow the student to learn how to do distinct types of notes that the PMHNP might be called upon to write during their career.? Therapy notes are meant to be brief and often follow the Data, Assessment, Plan (DAP) format. 

D– Data= This section should include what behaviors were observed during the therapy Focus of the session, topics discussed, and what the client tells you about the problem and symptoms. Relate to diagnosis, use quotes, and include specific details (frequency, severity, duration, etc.) and impact on functioning. Include the status of risk issues, if any (substance abuse, danger to self/others, etc.) 

A– Assessment= Therapist thoughts and assessment of client progress and the medical necessity for treatment. Assess barriers to progress or regression. Describe unusual appearance, thinking, and/or behavior. Note changes to diagnosis. 

P– Plan= What did you do? What do you plan to do? Include therapist in-session Interventions (ex.  “Cognitive reframing, “taught progressive relaxation”), referrals, and homework assigned. Include reminders for planned actions for future sessions and changes to the treatment plan (ongoing lack of progress should lead to a change in the treatment plan. 

Important: Therapy notes are not a part of the regular patient chart. However, they should be released to patients if it is determined that the contents could be psychologically harmful. 

Example Behavioral Therapy Note 

D– Met with M for 45 minutes via virtual session. Today she reports that she is in training at Amazon, which is going well. She reports that she is anxious about the 2-hour bus ride and that her work hours are overnight, so she is coming/ going in the dark. She is also worried about having too many badges to scan at work and is afraid she will ‘mess up.’  She states she was anxious about finding her way in the large building, but there are markings on the floor to guide her and after a few days, she feels more at ease. She does not want to return to community college now that she has found this employment that is not a seasonal job.  

A– Monica has improved her anxiety symptoms and seems proud of her progress and accomplishments with the new job. We discussed her past patterns of putting pressure on herself and overthinking. She has already overcome one obstacle by navigating the large building and can use the same skills for the other stressors that cause her anxiety at this new job.  

P– HW: Breathing and mindfulness techniques when feeling anxious and speaking up politely if feeling overwhelmed at the new job. Talk with the grandmother about not going back to college—next session in 1 week.