Addiction Counseling Progress Note

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Exempel — genererat av Notat från ett exempelbesök

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Mall

Client Identification:
[Client name, age, gender, relevant background information, presenting concern]

Presenting Problem:
[Description of substance use or addictive behavior, duration, frequency, context, and impact on functioning]

History of Present Illness:
[Chronological account of substance use or addictive behavior, triggers, patterns, previous attempts to quit or reduce, periods of abstinence, relapses, and associated symptoms]

Past Psychiatric History:
(hyphenated list)
- [Previous psychiatric diagnoses]
- [Prior mental health treatment or hospitalizations]
- [History of self-harm or suicidal ideation]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [History of hospitalizations or surgeries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include psychiatric and non-psychiatric medications]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]
- [No known allergies if applicable]

Family History:
(hyphenated list)
- [Family history of substance use, addiction, or psychiatric disorders]
- [Other relevant family medical history]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration, quit date if applicable]
- [Alcohol use: type, amount, frequency]
- [Other substances: type, amount, frequency]
- [Living situation: who lives with client, home environment]
- [Relationship status and supports]
- [Employment/education status]
- [Legal issues or involvement]
- [Financial situation]

Mental Status Examination:
(hyphenated list)
- [Appearance and behavior]
- [Mood and affect]
- [Speech and language]
- [Thought process and content]
- [Perceptual disturbances]
- [Cognition]
- [Insight and judgment]

Risk Assessment:
(hyphenated list)
- [Suicidal ideation or intent]
- [Homicidal ideation or intent]
- [Risk to self or others]
- [Risk of overdose or withdrawal complications]

Assessment:
(hyphenated list)
- [Summary of substance use/addictive behavior]
- [Co-occurring psychiatric or medical conditions]
- [Client strengths and barriers to change]
- [Motivation and readiness for change]

Plan:
(hyphenated list)
- [Immediate safety interventions if needed]
- [Counselling goals and objectives]
- [Therapeutic interventions planned (e.g., CBT, motivational interviewing, relapse prevention)]
- [Referrals to other services (e.g., medical, psychiatric, social supports)]
- [Client education and harm reduction strategies]
- [Follow up plan and frequency of sessions]
- [Return precautions or crisis plan]