A Formatted Session Note

What You Do:

1. You use pop-down list boxes to select the Service provided (the name of the CPT code) and the Therapy Modality utilized: In the example below, the service was 45-50 min individual psychotherapy, and the modality was cognitive-behavioral therapy.
2. You type or dictate the session note, using the Outline headings (Mental status, Observatons, Plan)

This is what the panel looks like:

What You Get

Below is a sample of the output obtained when you print your session note. Look for the following features:

• Centered clinic name and address (automatic)
• date of session (automatic)
• participant(s) (automatic)
• Problem (diagnosis) (automatic)
• treatment (CPT code with duration) (automatic)
• therapy modality (cognitive; hypnosis, etc.) (automatic)
• change in medications (automatic if changed in med panel)
• overall treatment plan per intake (automatic)
• body of text with Outline headings (whatever you type)
• signature and date line (automatic)

Not bad, eh? Here is what it looks like:

Mental Health Solutions, S.C.
7663 Ganser Way, Suite 204
Madison, Wisconsin 53719
Telephone: 608 829-1800
Fax: 608 829-1885
info@mhsolutions.com

Therapy session record
(Finalized)
Client: John Doe
Client ID: 123456789
Date: 5/3/99
Therapist: David A. Goldfoot,PhD
Participants:

John Doe

Service:
indiv psychotherapy 45-50 min

Problem
300.4, Dysthymic Disorder (Neurotic Depression) (3/23/99)

Treatment modality utilized in this session:
Cognitive-Behavioral therapy

MENTAL STATUS:
John is feeling considerably better today. He reports no sleep disturbance in the past two weeks and is no longer having anhedonic symptoms. No evidence of lethality or feeling helpless/hopeless.

OBSERVATIONS:
John is working regularly, having some problems with his employer, feeling that his supervisor is giving him too much without recognizing his circumstances. He will try to have a talk with him later this week. John has been using our event shet and is doing a good job on cognitive restructuring exercises.

PLAN:
John is to continue using the CR sheets. He will arrange for the meeting with his supervisor, but will rehearse options. His girlfriend will help him with this. He is to return in 2-3 weeks.

Overall Treatment Plan:
• Duration estimate: 6-10 sessions
• Frequency: 2 X month
• Mode: individual
• Ancillary recommendation: AA or aftercare program br>• Cognitive-Behavioral therapy
• Relaxation training

Signed________________________________________Date_________________