These assignments allow the student to learn how to do distinct types of notes that the PMHNP might be called upon to write during 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 Focus of the session, topics discussed, and what the client tells you about the problem and symptoms. Relate to diagnosis, use quotes, and include specific details (frequency, severity, duration, etc.) and impact on functioning. Include the status of risk issues, if any (substance abuse, danger to self/others, etc.) A- Assessment= Therapist thoughts and assessment of client progress and the medical necessity for treatment. Assess barriers to progress or regression. Describe unusual appearance, thinking, and/or behavior. Note changes to diagnosis. P- Plan= What did you do? What do you plan to do? Include therapist in-session Interventions (ex. “Cognitive reframing, “taught progressive relaxation”), referrals, and homework assigned. Include reminders for planned actions for future sessions and changes to the treatment plan (ongoing lack of progress should lead to a change in the treatment plan. Important: Therapy notes are not a part of the regular patient chart. However, they should be released to patients if it is determined that the contents could be psychologically harmful. Example Behavioral Therapy Note D- Met with M for 45 minutes via virtual session. Today she reports that she is in training at Amazon, which 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 is afraid she will ‘mess 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 feels more at ease. She does not want to return to community college now that she has found this employment that is not a seasonal job. A- Monica has improved her anxiety symptoms and seems proud of her progress and accomplishments with the new job. We discussed her past patterns of putting pressure on herself and overthinking. 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 and speaking up politely if feeling overwhelmed at the new job. Talk with the grandmother about not going back to college—next session in 1 week. Rubric
Psychiatric Therapy Note
Psychiatric Therapy Note
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeD (Data)
30 to >27.0 ptsAccomplished
Behaviors observed during the therapy were identified. Focus of the session, topics discussed present, Statements made by participant regarding their problem and symptoms present. detained and what the client tells you about the problem and symptoms. Relate to diagnosis, use quotes, and include specific details (frequency, severity, duration, etc.) and impact on functioning. Include the status of risk issues, if any (substance abuse, danger to self/others, etc.)
27 to >24.0 ptsSatisfactory
Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details. Some extraneous data present with 1 minor data point missing.
24 to >22.0 ptsNeeds Improvement
Symptom analysis is not well organized or presented in a varied format. Required data is missing. There is too much extraneous data present or 2-3 minor data points are missing.
22 to >0 ptsUnsatisfactory
Symptom analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data. Important data is missing.
30 pts
This criterion is linked to a Learning OutcomeA (Assessment)
30 to >27.0 ptsAccomplished
Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data. Includes: 1 working Dx and 2 Differential Dx.
27 to >24.0 ptsSatisfactory
Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing at least one (1) pertinent differential diagnosis not listed according to subjective and objective data. Working diagnosis is correct.
24 to >22.0 ptsNeeds Improvement
Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing up to two (2) pertinent differential diagnoses based on subjective and objective data presented. Or differential diagnoses are adequate with an incorrect working diagnosis.
22 to >0 ptsUnsatisfactory
All diagnoses (working diagnosis and differential diagnoses) are incorrect or is missing based on the subjective and objective data presented.
30 pts
This criterion is linked to a Learning OutcomeP (Plan)
30 to >27.0 ptsAccomplished
Plan is well-organized, complete, evidence-based, and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. *Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medications identified; therapy recommendations; patient education; referral/follow-up; and health maintenance.
27 to >24.0 ptsSatisfactory
Plan is organized, complete, evidence-based and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. Plan is missing 1-2 of the required items.
24 to >22.0 ptsNeeds Improvement
Plan is less organized, is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric Plan is missing more than 2 of the required items.
22 to >0 ptsUnsatisfactory
Plan is disorganized, absent, or is missing all the required items.
30 pts
This criterion is linked to a Learning OutcomeOrganization/ Professionalism
10 to >8.0 ptsAccomplished
The therapy note is well organized, concise, and uses professional terms.
8 to >5.0 ptsSatisfactory
The therapy note is mainly organized and has 1-2 minor grammar mistakes or information placement.
5 to >4.0 ptsNeeds Improvement
There are several mistakes in the placement of information or word choice impact the organization and clarity of the therapy note.
4 to >0 ptsUnsatisfactory
There are numerous mistakes in wording and placement of information. The ltherapy note is not well organized, unprofessional, and challenging to understand.
10 pts
Total Points: 100