S=Subjective: client’s view of problems or progress noted, use client’s own words
Client arrived to appointment on time and stated that she “had a good week”. She reported an improvement in mood and gave examples of activities that she had engaged in during the week (eg. attending church, work and a family event).
O=Objective: therapist’s objective observations of the client’s progress
Client presented congruent to her account. She maintained eye contact and responded appropriately to questions from counselor. She appeared to have given an accurate account of the activities she had engaged in and showed signs of improved mood.
A=Assessment: therapist’s assessment of the client’s affect, mental status, and psychological functioning
Note client’s mood (anxious, angry, depressed, euphoric, irritable other), cognition (orientation to person, place & time; memory impairment none, short-term, long term; and attention, normal or distracted), perception (hallucinations – none, auditory, visual or olfactory), thoughts (suicidal – none, ideation, plan, intent or self-harm, homicidal-none, aggressive, intent or plan, or delusional – none, grandiose, paranoid, religious), behavior (cooperative, guarded, hyperactive, agitated, paranoid, stereotyped, aggressive, bizarre, withdrawn), insight (good, fair or poor) and judgment (good, fair or poor).
Client presented with slightly elevated mood and was oriented x3. Client showed no impairment in memory or attention and reported no hallucinations. Client denied suicidal, homicidal and delusional thoughts and willingly cooperated with counseling process. Client showed good insight and fair judgment. Client appears to be making progress to decrease symptoms of depression based on oral report and presented affect.
P=Plan: plan for future treatment as it relates to progress noted
Client will continue current course of treatment including attending weekly individual counseling sessions, keeping a log of outside activities participated in each week to increase social skills, and reciting daily affirmations selected in session. Client has scheduled follow up appointment for Monday, January 3rd at 3:00pm. BDI-II follow up screening will be completed at this session.