As a mental health provider, your job is to document daily with the client you interact with.
Create an example of a thorough progress note on the information given:
REHAB GOALS: “I want to connect with others in my community. I also want to get more involved in my spiritual outreach.”
OBJECTIVE: Client will utilize those 4 learned skills to overcome identified triggers to his PTSD.
Baseline Measured: Client currently utilizes zero (0) learned skills in avoiding or coping with identified triggers to his PTSD.
Target:Client to practice 3-4 learned skills and or recovery strategies in dealing with his anxiety and depression, learning those recovery strategies of how to stay confident while controlling his thoughts from his past.
Interventions: 1. Mental Health Practitioner will facilitate sessions through roleplays on scenarios that could trigger client’s emotional breakdowns, lead client into extreme stress, PTSD and anxiety.
The practitioner shall roleplay with client in identifying triggers and ways to cope, such as social support, relaxation skills, and change of environment.
2. MHP will also assist client with community intervention needs, such as matching client with resources in the community.
3. Client to attend psychosocial coaching and review prevention steps, and information, personalizing a full PTSD trigger prevention plan that includes identifying situations that may lead to panic and coping skills.
Progress notes example:
MHP follow-up with the client to review the use of skills utilized during the previous session. MHP continues to psycho-educated him on the fear of being out in the community. He was also coached on how he can implement the skill of mindful meditation to cope with both symptoms. The client was engaged in discussing his depressive and anxiety triggers and what he does to cope with them. MHP coached him on engaging in some deep breathing every morning as a way to begin his day and to motivate him to engage in other activities.
Client response: The client states he fears walking outside and something terrible happening. He participated in identifying his depressive and anxiety triggers and ways to overcome them. The client engaged very well in the deep breathing activities.
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