23 Jan In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the clients chart following th
Topic 6 DQ 1 In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers' SOAP notes. Would you have documented anything differently? Why or why not? 350 words
Topic 6 DQ 2 In Topic 5, you created a treatment plan for your client. If your client was to attend a group therapy session, write a progress note for that client’s participation in that group. How is writing a group progress note different than an individual progress note? 400 words
Treatment Plan
Based on the information collected in Week 4, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client's strengths and support system in the treatment plan.
Client: ____Eliza________________________________________ Date: ______________ Age: ______ DOB: __________________
|
DSM Diagnosis |
ICD Diagnosis |
|
Depression |
Mild depressive disorder |
|
Goals / Objectives: |
Interventions: |
Frequency: |
|
□ Mood Stabilization |
□ Psychotropic Medication Referral & Consultation □ Journaling □ Cognitive Behavior Therapy □ Skill Training □ Emotion Recognition – Regulation Techniques |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Anxiety Reduction |
□ Psychotropic Medication Referral & Consultation □ Journaling □ Cognitive Behavior Therapy □ Skill Training □ Relaxation Techniques |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Reduce Obsessive Compulsive Behaviors |
□ Psychotropic Medication Referral & Consultation □ Journaling □ Cognitive Behavior Therapy □ Skill Training |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Decrease Sensitivity to Trauma Experiences |
□ Verbalize Memories Triggers &Emotion □ Desensitize Trauma Triggers and Memories □ Utilize Healing Model/Support (Mending the Soul) |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Establish and Maintain Eating Disorder Recovery |
□ Overcome Denial □ Identify Negative Consequences □ Menu Planning □ Nutrition Counseling □ Body Image Work □ Healthy Exercise □ Trigger Mgmt. Recovery Plan □ CBT |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Maintain Abstinence from substances (Alcohol/Drugs) |
□ Substance Use Assessment □ Stepwork □ Overcome Denial □ Identify Negative Consequences □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Increase Coping Skills |
□ DBT Skills Training □ Problem Solving Techniques □ Emotion Recognition & Regulation □ Communication Skills |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Stabilize, Adjustment to New Life Circumstances |
□ Alleviate Distress □ Cognitive Behavior Therapy □ Stress Management □ Skills Training □ Improve Daily Functioning □ Develop Healthy Support |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Decrease/Eliminate Self Harmful Behaviors |
□ Cognitive Behavior Therapy □ Skills Training □ Develop and Utilize Support System |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Improve Relationships |
□ Communication Skills □ Active Listening □ Family Therapy □ Assertiveness □ Setting Healthy Boundaries |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Improve Self Worth |
□ Affirmation Work □ Positive Self Talk □ Skills Training □ Confidence Building Tasks |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Grief Reduction and Healing from Loss |
□ Psychoeducation on Grief Process/ Stages □ Process Feeling □ Emotion Regulation Techniques □ Reading/Writing Assignments □ Develop/Utilize Support |
□ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family |
|
□ Develop Anger Management Skills |
□ Decrease Anger Outbursts □ Emotion Regulation Techniques □ Cognitive Behavior Therapy □ Increase Awareness/Self Control |
□ Weekly □ Bi Weekly □ Monthly □ other: __________________ □ Group □ Individual □ Family |
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