The Adult Psychotherapy Progress Notes Planner. David J. Berghuis
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to the numbers of the Behavioral Definitions from the Treatment Planner.
The second section of each chapter, “Interventions Implemented,” provides a menu of statements related to the action that was taken within the session to assist the client in making progress. The numbering of the items in the Interventions Implemented section follows exactly the numbering of Therapeutic Intervention items in the corresponding Treatment Planner.
All item lists begin with a few keywords. These words are meant to convey the theme or content of the sentences that are contained in that listing. The clinician may peruse the list of keywords to find content that matches the client's presentation and the clinician's intervention.
It is expected that the clinician may modify the prewritten statements contained in this book to fit the exact circumstances of the client's presentation and treatment. To maintain complete client records, in addition to progress note statements that may be selected and individualized from this book, the date, time, and length of a session; those present within the session; the provider; the provider's credentials; and a signature must be entered in the client's record.
A FINAL NOTE ABOUT PROGRESS NOTES AND HIPAA
Federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) govern the privacy of a client's psychotherapy notes, as well as other protected health information (PHI). PHI and psychotherapy notes must be kept secure and the client must sign a specific authorization to release this confidential information to anyone beyond the client's therapist or treatment team. Further, psychotherapy notes receive other special treatment under HIPAA; for example, they may not be altered after they are initially drafted. Instead, the clinician must create and file formal amendments to the notes if he or she wishes to expand, delete, or otherwise change them.
Does the information contained in this book, when entered into a client's record as a progress note, qualify as a “psychotherapy note” and therefore merit confidential protection under HIPAA regulations? If the progress note that is created by selecting sentences from the database contained in this book is kept in a location separate from the client's PHI data, then the note could qualify as psychotherapy note data that is more protected than general PHI. However, because the sentences contained in this book convey generic information regarding the client's progress, the clinician may decide to keep the notes mixed in with the client's PHI and not consider it psychotherapy note data. In short, how you treat the information (separated from or integrated with PHI) can determine if this progress note planner data is psychotherapy note information. If you modify or edit these generic sentences to reflect more personal information about the client or if you add sentences that contain confidential information, the argument for keeping these notes separate from PHI and treating them as psychotherapy notes becomes stronger. For some therapists, our sentences alone reflect enough personal information to qualify as psychotherapy notes and they will keep these notes separate from the client's PHI and require specific authorization from the client to share them with a clearly identified recipient for a clearly identified purpose.
ANGER CONTROL PROBLEMS
CLIENT PRESENTATION
1 Episodic Excessive Anger (1)1The client described a history of loss of temper in response to specific situations.The client described a history of loss of temper that dates back many years, including verbal outbursts and property destruction, typically related to specific emotional themes.As treatment has progressed, the client has reported increased control of his/her/their situational episodic excessive anger.The client has had no recent incidents of episodic excessive anger.
2 General Excessive Anger (2)The client shows a pattern of general, excessive anger across many situations.The client does not appear to be experiencing anger in response to specific issues, but as a general pattern.As treatment has progressed, the client has verbalized insight into his/her/their pattern of excessive anger.The client has made progress in controlling his/her/their pattern of excessive anger.
3 Cognitive Biases Toward Anger (3)The client shows a pattern of cognitive biases commonly associated with anger.The client makes demanding expectations of others.The client tends to generalize labeling the targets of his/her/their anger.The client tends to have anger in reaction to perceived slights.As treatment has progressed, the subject displays decreased patterns of cognitive biases associated with anger.
4 Evidence of Physiological Arousal (4)The client displayed direct evidence of physiological arousal in relation to his/her/their feelings of anger.The client displays indirect evidence of physiological arousal related to his/her/their feelings of anger.As treatment has progressed, the subject's level of physiological arousal has decreased as anger has become more managed.
5 Explosive, Destructive Outbursts (5)The client described a history of loss of temper in which he/she/they have destroyed property during fits of rage.The client described a history of loss of temper that dates back to childhood, involving verbal outbursts as well as property destruction.As therapy has progressed, the client has reported increased control over his/her/their temper and a significant reduction in incidents of poor anger management.The client has had no recent incidents of explosive outbursts that have resulted in destruction of property or intimidating verbal assaults.
6 Explosive, Assaultive Outbursts (5)The client described a history of loss of anger control to the point of physical assault on others who were the target of his/her/their anger.The client has been arrested for assaultive attacks on others when he/she/they have lost control of his/her/their temper.The client has used assaultive acts as well as threats and intimidation to control others.The client has made a commitment to control his/her/their temper and terminate all assaultive behavior.There have been no recent incidents of assaultive attacks on anyone, in spite of the client having experienced periods of anger.
7 Overreactive Irritability (6)The client described a history of reacting too angrily to rather insignificant irritants in his/her/their daily life.The client indicated that he/she/they recognize that he/she/they become too angry in the face of rather minor frustrations and irritants.Minor irritants have resulted in explosive, angry outbursts that have led to destruction of property and/or striking out physically at others.The client has made significant progress at increasing frustration tolerance and reducing explosive overreactivity to minor irritants.
8 Physical/Emotional Abuse (7)The client reported physical encounters that have injured others or have threatened serious injury to others.The client showed little or no remorse for causing pain to others.The client projected blame for his/her/their aggressive encounters onto others.The client has a violent history and continues to interact with others in a very intimidating, aggressive style.The client has shown progress in controlling his/her/their aggressive patterns and seems to be trying to interact with more assertiveness rather than aggression.
9 Harsh Judgment Statements (8)The client exhibited frequent incidents of being harshly critical of others.The client's family members reported that he/she/they react very quickly with angry, critical, and demeaning language toward them.The client reported that he/she/they have been more successful at controlling critical and intimidating statements made to or about others.The client reported that there have been no recent incidents of harsh, critical, and intimidating statements made to or about others.
10 Angry/Tense Body Language (9)The client presented with verbalizations of anger as well as tense, rigid muscles and glaring facial expressions.The client expressed his/her/their anger with bodily signs of muscle tension, clenched fists, and refusal to make eye contact.The client appeared more relaxed, less angry, and did not exhibit physical signs of aggression.The client's family reported that he/she/they have been more relaxed within the home setting and has not shown glaring looks or pounded his/her/their fist on the table.
11 Passive-Aggressive Behavior (10)The client described a history of passive-aggressive behavior in which he/she/they would not comply with directions, would complain about authority figures behind their backs, and would not meet expected behavioral norms.The client's family confirmed a pattern of the client's passive-aggressive