Problem
Oriented Progress Note
Jim Doe
nAug 30, 01 Indiv office 1430 to 1550
Data: “I’m doing better but
I was really ticked at my wife all week”. Reports more arguments but fewer explosive episodes. Discussed family
of origin for patterns similar to this. Pt.
Problems: Focused on
communication and interaction patterns with wife and children that lead to conflict and increased
anger. Examined automatic self
defeating thoughts.
Treatment: Cognitive
therapy. Education – Taught thought detection
and thought selection.
Evaluation: Self assessment
SUD=5 and 2 at end of session. Client successfully examined, selected and developed
alternatives based on healthy
alternative thoughts. Increased confidence evidenced by relaxation responses and self-assessment
Follow-up: Remain on Tx
plan issues with wife. Practice what
he learned outside Tx.
Review progress next session