Week 6 Collaborative Learning: Psychiatric Therapy Note

The purpose of these assignments are to allow the student to learn  how to do various types of notes that the PMHNP might be called upon to  write in the course of 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 and anything that might be pertinent to how you want to  proceed with the therapy treatments.

A- Assessment= What is your  assessment of the behaviors and what do they mean in relation to the  therapy you are using. What do you think the clientàactions mean? Are  the clients progressing toward the goals?

P- Plan= Record the treatment plan for your patient.

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

Example:

D-  Met with M for 45 minutes via virtual session.  Today she is reporting  that she is in training at Amazon and it 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 afraid she will ess  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 is feeling more at ease. She is not wanting to return to  community college now that she has found this employment that is not a  seasonal job. 

A- Monica has made improvement in her anxiety  symptoms and seems quite proud of her progress and accomplishments with  the new job. We discussed her past patterns of putting pressure on  herself and over thinking. 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. Speaking up  politely if feeling overwhelmed at new job. Talk with grandmother about  not going back to college. Next session in 1 week.