Information
Released to 3rd Party Payer Under HIPPA - Example
nScreening/Assessment
nSymptoms: insomnia, loss of appetite, low energy, loss
of usual interest, agitation, low
self-esteem, guilt, worry
nResults of clinical tests: Depression, internalizing,
severe
nFunctional Status:
DSM Axis IV GAF 60 (current)
nDiagnosis: DSM Axis I 296.2, Axis II No diagnosis Axis
III No reported problems
nTx Plan
nSession start & stop times: (see log of
appointments)
nFrequency of Tx: one appointment weekly, 12 sessions,
re-evaluate monthly
nModality: Individual and referral to depression
education class
nTx Activity: Interpersonal & health education
nMedical prescription & monitoring: Medication
evaluation if no progress by 8th session
nProgress: routine, nominal improvement
nPrognosis: Good with continued treatment