Name: Judy A.

Sample
1/26/2016

ID: 1
Page #: 1

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

Clinical Record
Name:

Judy A. Sample

Provider:

Default Provider

Date:1/26/2016

Personal Data
ID: 1
Address: 111 Main St.
City:
State/Province:
Zip/Postal Code:
Home Phone:
Work Phone:
SSN:

Anywhere
MI
11111
(555)555-5555
(555)555-5555
555-55-5555

Birth Date:
Age:
Gender:
Race:
Marital Status:
Military Rank:
Treatment Start Date:
Treatment End Date:
Last Review:

Treatment Status:
Previously Treated?:
Pri. Care Physician:
Employer:
Referral Source:
Psychiatrist:
Setting:
Department:

7/7/1946
69
Female
Caucasian
Married
NA
8/7/2006

Active
No
Dr Smith
Sue Jackson
Outpatient
East Paris

Authorization Data
Insurance Carrier

Date Authorized

Start Date

End Date

Authorized Sessions

Authorization Number

Aetna

8/7/2006

8/7/2006

11/7/2006

989887

Total Sessions Authorized This Episode:

Assessment
Interviewer:

Default Provider

Sessions Used:

Interview Date:

8/7/2006

Sessions Remaining:

Person Interviewed:

Patient

Psychosocial History:
Family:

Developmental:
Substance Use:
Socio-Economic

Psychiatric:

Medical:

Judy indicates that her father was an anxious man who worried about everything. Judy was close to
him while she lived at home. Judy has been married to Bob for 40 years and they have two
daughters who are married and live close to Judy. She has a good relationship with her husband and
her daughters. Judy enjoys working in her garden but would like to entertain her friends more if she
was not so preoccupied with worry.
N/A
Judy denies any problems with use of alcohol or other mood altering drugs. There is no history of
substance use disorder in her family of origin nor with her husband.
Judy and Bob live alone in their own home. Bob is employed as engineer at a large corporation. Judy
was working as a school secretary until two years ago when she quit due to her overwhelming
worries. She denies any significant financial problems but she does worry about their retirement
finances. She and Bob attend church services quite regularly but she fears that God does not hear
her prayers for peace of mind.
Judy has never been in counseling before but her father was admitted to a psychiatric hospital one
time for about two weeks several years ago. Judy has been on Xanax from her Ob-Gyn physician,
Dr. Cole, for several months.
Judy complains of severe pain her back that has been with her for two years. She has been told that
surgery will not help. She worries that it may be something serious like cancer that has not been
found.

Strengths/Weaknesses
Strengths:
Weaknesses:

Stable Work History, Positive Support Network, Motivated for Change

Poor Health, Indecisive

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 2

SSN: 555-55-5555

Birthday: 7/7/1946

Assessments Completed:
Instrument/Interview

Date
Administered

Data Source

Result

Clinical Interview
Psychosocial History
Global Severity Index

8/7/2006
8/7/2006
8/7/2006

Patient
Patient
Patient

22.00

Global Severity Index

8/14/2006

Patient

11.00

Global Severity Index

9/11/2006

Patient

7.00

Treatment
Phase

Details

PreTreatment
During
Treatment
PostTreatment

Interpretation Note:

Mental Status:
Presentation

Date First Rated: 8/7/2006

Appearance:
Mood:
Attitude:
Affect:
Speech:
Motor Activity:
Orientation:

Mental Functioning
Simple Calculations:
Serial Sevens:
Immediate Memory:
Remote Memory:
General Knowledge:
Proverb Interpretation:
Similarities/Differences:

Higher Order Abilities

Judgment:
Insight:
Intelligence:

Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:

Risk Assessment

Well-Groomed
Anxious
Cooperative
Appropriate
Pressured
Tense
Fully Oriented
Date First Rated: 8/7/2006

Date Last Rated:

Accurate
Accurate
Intact
Intact
Accurate
Accurate
Accurate
Date First Rated: 8/7/2006

Date Last Rated:

Intact
Intact
High
Date First Rated: 8/7/2006

Date Last Rated:

Logical and Organized

None Evident
None Evident
Date First Rated: Date Last Rated:
8/7/2006

Suicide:
Violence:
Child Abuse:
Partner Abuse:
Elder/Parent Abuse:

Date Last Rated:

None
None
None
None
None

Latest Note:

Date:

Name: Judy A. Sample

ID: 1
1/26/2016
Page #: 3
Most Recent Mental Status Summary:

SSN: 555-55-5555

Birthday: 7/7/1946

Assessment Summary:
Recovery Assessment ASAM Patient Placement Criteria 2R:
Date: 8/21/2006
Six Dimensions
I.
Acute Intoxication and/or Withdrawal Potential
II.
Biomedical Conditions & Complications
III.
Emotional / Behavioral or Cognitive Conditions & Complications
IV.
Readiness to Change
V.
Relapse, Continued Use or Continued Problem Potential
VI.
Recovery / Living Environment
Level of Care:
Comment:

Severity
Medium
Low
High
Medium
Low
High

Level IV, Medically-Managed Intensive Inpatient Treatment

Recovery Assessment Stage of Change:

Problem: Anxiety
Date Assessed
8/7/2006

Stage of Change
Preparation

Problem: Chronic Pain

Date Assessed
Stage of Change
8/7/2006
Pre-contemplation

Comment

Comment

Diagnosis
Axis I

300.02

Generalized Anxiety Disorder

Axis II

V71.09

No Diagnosis

Axis III
Axis IV
Axis V

Chronic Back Pain

Health
Current: 51-60 Prior: 81-90
Stress Severity Rating: Moderate

Treatment Techniques
Treatment Modalities:
CPT Code
90806

Type
Indiv. OP Psychotherapy-45" no Med. Eval

Recommended
Level of care
Outpatient

Least Restrictive
Alternative?
Yes

Frequency
1 Weekly
Agreement with
level of care?
Yes

Provider
Default Provider
Is recommended level
of care available?
Yes

Modality Note:

Treatment Approaches:
The following treatment approaches are being implemented: Cognitive Restructuring, Behavioral Techniques
Approach Note:
Medication

Dosage

Frequency Start Date

End Date

Prescribed by Note

Date:

Name: Judy A. Sample

1/26/2016
Xanax
5mg.

ID: 1
SSN: 555-55-5555
Page #: 4
1x/day
8/7/2006
Dr.Jones

Birthday: 7/7/1946

Date:

Presenting Problems
Primary Anxiety
Secondary Chronic Pain

Treatment Plan
Primary Problem:
Behavioral Definition

Anxiety

Excessive and/or unrealistic worry that is difficult to control occurring more days than not for at least 6 months about a
number of events or activities.
Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).
Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry mouth, trouble swallowing, nausea, diarrhea).
Hypervigilance (e.g., feeling constantly on edge, experiencing concentration difficulties, having trouble falling or staying
asleep, exhibiting a general state of irritability).

Long-term Goals

Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.

Short-Term Objectives

Therapeutic Interventions

Describe current and past experiences with the worry

and anxiety symptoms, complete with their impact on
functioning and attempts to resolve it.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Assess the focus, excessiveness, and uncontrollability of

the client's worry and the type, frequency, intensity, and
duration of her anxiety symptoms (e.g., The Anxiety
Disorders Interview Schedule for the DSM-IV by DiNardo,
Brown, and Barlow).
Entry Date: 8/7/2006

Verbalize an understanding of the cognitive,

physiological, and behavioral components of anxiety
and its treatment.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Discuss how generalized anxiety typically involves

excessive worry about unrealistic threats, various bodily
expressions of tension, overarousal, and hypervigilance,
and avoidance of what is threatening that interact to
maintain the problem (see Mastery of Your Anxiety and
Worry - Therapist Guide by Craske, Barlow, and O'Leary).
Entry Date: 8/7/2006

Learn and implement calming skills to reduce overall

anxiety and manage anxiety symptoms.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Provider:

Teach the client relaxation skills (e.g., progressive muscle

relaxation, guided imagery, slow diaphragmatic breathing)
and how to discriminate better between relaxation and
tension; teach the client how to apply these skills to her
daily life (e.g., Progressive Relaxation Training by
Bernstein and Borkovec; Treating GAD by Rygh and
Sanderson).
Entry Date: 8/7/2006

Provider:

Discuss how treatment targets worry, anxiety symptoms,

and avoidance to help the client manage worry effectively
and reduce overarousal and unnecessary avoidance.
Entry Date: 8/7/2006

Provider:

Assign the client to read psychoeducational sections of

books or treatment manuals on worry and generalized
anxiety (e.g., Mastery of Your Anxiety and Worry - Client
Guide by Zinbarg, Craske, Barlow, and O'Leary).
Entry Date: 8/7/2006

Provider: Default Provider

Provider:

Assign the client homework each session in which she

practices relaxation exercises daily; review and reinforce

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 5

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

success while providing corrective feedback toward

improvement.
Entry Date: 8/7/2006

Entry Date: 8/7/2006

Verbalize an understanding of the role that cognitive

biases play in excessive irrational worry and persistent

anxiety symptoms.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Identify, challenge, and replace biased, fearful selftalk with positive, realistic, and empowering self-talk.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Undergo gradual repeated imaginal exposure to the

feared negative consequences predicted by worries
and develop alternative reality-based predictions.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Provider:

Select initial exposures that have a high likelihood of being

a success experience for the client; develop a plan for
managing the negative affect engendered by exposure;
mentally rehearse the procedure.
Entry Date: 8/7/2006

Provider:

Direct and assist the client in constructing a hierarchy of

two to three spheres of worry for use in exposure (e.g.,
worry about harm to others, financial difficulties,
relationship problems).
Entry Date: 8/7/2006

Provider:

Assigned homework for Making Use of the ThoughtStopping Technique

Entry Date: 8/7/2006

Provider:

Teach the client to implement a thought-stopping technique

(thinking of a stop sign and then a pleasant scene) for
worries that have been addressed but persist (or assign
"Making Use of the Thought-Stopping Technique" in Adult
Psychotherapy Homework Planner, 2nd ed. by Jongsma);
monitor and encourage the client's use of the technique in
daily life between sessions.
Entry Date: 8/7/2006

Provider:

Explore the client's schema and self-talk that mediate her

fear response; challenge the biases; assist her in replacing
the distorted messages with reality-based alternatives and
positive self-talk that will increase her self-confidence in
coping with irrational fears.
Entry Date: 8/7/2006

Provider:

Assigned homework for Journal and Replace SelfDefeating Thoughts

Entry Date: 8/7/2006

Provider:

Assist the client in analyzing her fear by examining the

probability of the negative expectation occurring, the real
consequences of it occurring, her ability to control the
outcome, the worst possible outcome, and her ability to
accept it (see "Analyze the Probability of a Feared Event"
in Adult Psychotherapy Homework Planner, 2nd ed. by
Jongsma, and Anxiety Disorders and Phobias by Beck and
Emery).
Entry Date: 8/7/2006

Provider:

Assign the client to read about progressive muscle

relaxation and other calming strategies in relevant books or
treatment manuals (e.g., Progressive Relaxation Training
by Bernstein and Borkovec; Mastery of Your Anxiety and
Worry - Client Guide by Zinbarg, Craske, Barlow, and
O'Leary).
Entry Date: 8/7/2006

Provider:

Use biofeedback techniques to facilitate the client's success

at learning relaxation skills.

Provider:

Assign the client a homework exercise in which she does

worry exposures and records responses (see Mastery of
Your Anxiety and Worry - Client Guide by Zinbarg,
Craske, Barlow, and O'Leary or Generalized Anxiety
Disorder by Brown, O'Leary, and Barlow); review,
reinforce success, and provide corrective feedback toward

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 6

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

improvement.
Entry Date: 8/7/2006

Maintain involvement in work, family, and social

activities.
Entry Date: 8/7/2006
Projected Sessions:

Secondary Problem:
Behavioral Definition

Target Date:
Critical? No

Provider:

Support the client in following-through with work, family,

and social activities rather than escaping or avoiding them
to focus on panic.
Entry Date: 8/7/2006

Provider:

Chronic Pain

Has decreased or stopped activities such as work, household chores, socializing, exercise, sex, or other pleasurable
activities because of pain.
Makes statements like "I can't do what I used to"; "No one understands me"; "Why me?"; "When will this go away?"; "I
can't take this pain anymore"; and "I can't go on."
Complains of generalized pain in many joints, muscles, and bones that debilitates normal functioning.

Long-term Goals

Regulate pain in order to maximize daily functioning and return to productive employment.

Short-Term Objectives

Therapeutic Interventions

Describe the nature of, history of, impact of, and

understood causes of chronic pain.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Assess the history and current status of the client's chronic

pain.
Entry Date: 8/7/2006

Entry Date: 8/7/2006

Complete a thorough medication review by a

physician who is a specialist in dealing with chronic
pain or headache conditions.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Participate in a cognitive behavioral group therapy for

pain management.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Identify and monitor specific pain triggers.

Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Learn and implement somatic skills such as relaxation

and/or biofeedback to reduce pain level.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Provider:

Teach the client relaxation skills (e.g., progressive muscle,

guided imagery, slow diaphragmatic breathing) and how to
discriminate better between relaxation and tension; teach
the client how to apply these skills to her daily life (see
Progressive Relaxation Training by Bernstein and
Borkovec).
Entry Date: 8/7/2006

Provider:

Teach the client self-monitoring of her symptoms; ask the

client to keep a pain journal that records time of day, where
and what she was doing, the severity, and what was done to
alleviate the pain (or assign "Pain and Stress Journal" in
Adult Psychotherapy Homework Planner, 2nd ed. by
Jongsma); process the journal with the client to increase
insight into nature of the pain, cognitive, affective, and
behavioral triggers, and the positive or negative effect of
the interventions they are currently using.
Entry Date: 8/7/2006

Provider:

Form a small, closed enrollment group (4-8 clients) for

pain management (see Group Therapy for Patients with
Chronic Pain by Keefe, Beaupre, Gil, Rumble, and
Aspnes).
Entry Date: 8/7/2006

Provider:

Ask the client to complete a medication review with a

specialist in chronic pain or headaches; confer with the
physician afterward about her recommendations and
process them with the client.
Entry Date: 8/7/2006

Provider:

Explore the changes in the client's mood, attitude, social,

vocational, and familial/marital roles that have occurred as
a result of the pain.

Provider:

Identify areas in the client's life that she can implement

Name: Judy A. Sample

1/26/2016

ID: 1
Page #: 7

SSN: 555-55-5555

Birthday: 7/7/1946

Date:

skills learned through relaxation or biofeedback.

Entry Date: 8/7/2006

Entry Date: 8/7/2006

Identify negative pain-related thoughts and replace

them with more positive coping-related thoughts.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Integrate and implement new mental, somatic, and

behavioral ways of managing pain.
Entry Date: 8/7/2006
Projected Sessions:

Target Date:
Critical? No

Provider:

Assign the client to read about cognitive restructuring in

relevant books or treatment manuals (e.g., The Chronic
Pain Control Workbook by Catalano and Hardin).
Entry Date: 8/7/2006

Provider:

Assign the client a homework exercise in which she

identifies negative pain-related self-talk and positive
alternatives (or assign "Journal and Replace Self-Defeating
Thoughts" in Adult Psychotherapy Homework Planner, 2nd
ed. by Jongsma); review and reinforce success, providing
corrective feedback toward improvement.
Entry Date: 8/7/2006

Provider:

Explore the client's schema and self-talk that mediate her

pain response, challenging the biases; assist her in
generating thoughts that correct for the biases, facilitate
coping, and build confidence in managing pain.
Entry Date: 8/7/2006

Provider:

Assign the client to read about progressive muscle

relaxation and other calming strategies in relevant books or
treatment manuals (e.g., Progressive Relaxation Training
by Bernstein and Borkovec).
Entry Date: 8/7/2006

Provider:

Assign a homework exercise in which the client

implements somatic pain management skills and records
the result; review and process during the treatment session.

Provider:

Assist client in integrating learned pain management skills

(e.g., relaxation, distraction, activity scheduling) into a
progressively wider range of daily activities; record and
review.
Entry Date: 8/7/2006

Provider:

Response to Plan
Response to treatment plan presentation:
Significant Other response to treatment plan presentation:
I, Judy A. Sample, have reviewed this treatment plan.
x. _______________________________________________

Date: ______________________________

Progress Notes
Session 1

Date: 8/7/2006
Time: 9:00 AM to 10:00 AM
Modality: Individual Psychotherapy

(60 min)

Progress Rating: Some Progress

CPT Code:

Psychotherapy Note:

Judy has shared her symptoms of anxiety. She experinces worry surrounding her safety but cannot explain why she should feel
so threatened. She is afraid to make many decisons as she fears some dire consequence. She is tense and feels nauseous often.

Provider Signature:
Default Provider

1/26/2016
Date

Name: Judy A. Sample

ID: 1
SSN: 555-55-5555
1/26/2016
Page #: 8
Session 2 Date: 8/14/2006
Time: 9:00 AM to 10:00 AM (60 min)
Modality: Individual Psychotherapy
Problem Addressed: Anxiety
Patient Presentation (Signs and Symptoms)
The client related that she is constantly feeling on edge, that
sleep is interrupted, and that concentration is difficult.
The client described a history of restlessness, tiredness,
muscle tension, and shaking.
The client reported the presence of symptoms such as heart
palpitations, dry mouth, tightness in the throat, and some
shortness of breath.
Problem Addressed: Chronic Pain
Patient Presentation (Signs and Symptoms)
The client has complained of pain throughout her body and in
many joints, muscles, and bones.
The client has significantly decreased or stopped activities
related to work, household chores, socialization, exercise, and
sexual pleasure because of pain.
The client made frequent pessimistic verbalizations about her
inability to control the pain or live a normal life or be
understood by others.

Birthday: 7/7/1946

Date:

Progress Rating:
CPT Code:

Interventions Implemented
The client was taught about how anxious fears are maintained
by a cycle of unwarranted fear and avoidance that precludes
positive, corrective experiences with the feared object or
situation.
A discussion was held about how treatment targets worry,
anxiety symptoms, and avoidance to help the client manage
worry effectively.

Interventions Implemented
A history of the client's experience of chronic pain and her
associated medical conditions was gathered.
The changes in the client's social, vocational, familial, and
intimate life that have occurred in reaction to her pain were
explored.

Psychotherapy Note:
Provider Signature:

1/26/2016
Date

Default Provider

Session 3

Date: 8/23/2006
Time: 9:00 AM to 9:30 AM
Modality: Individual Psychotherapy

Progress Rating: No Change

CPT Code:

(30 min)

Psychotherapy Note:
Provider Signature:
Default Provider

1/26/2016
Date

Objective Ratings

Objectives Identified
Describe current and past experiences with the worry and anxiety symptoms, complete
with their impact on functioning and attempts to resolve it.
Verbalize an understanding of the cognitive, physiological, and behavioral components
of anxiety and its treatment.
Learn and implement calming skills to reduce overall anxiety and manage anxiety
symptoms.
Verbalize an understanding of the role that cognitive biases play in excessive irrational
worry and persistent anxiety symptoms.
Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and
empowering self-talk.
Undergo gradual repeated imaginal exposure to the feared negative consequences
predicted by worries and develop alternative reality-based predictions.
Maintain involvement in work, family, and social activities.

Critical?
No

First Progress
Rating:
8/7/2006
No Change

Last Progress
Rating:
8/23/2006
No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

Describe the nature of, history of, impact of, and understood causes of chronic pain.

No

No Change

No Change

Name: Judy A. Sample

ID: 1
SSN: 555-55-5555
1/26/2016
Page #: 9
a thorough medication review by a physician who is a specialist in dealing
Complete
with chronic pain or headache conditions.
Participate in a cognitive behavioral group therapy for pain management.

Birthday: 7/7/1946

Date:

No

No Change

No Change

No

No Change

No Change

No

No Change

No Change

Learn and implement somatic skills such as relaxation and/or biofeedback to reduce pain No
level.
Identify negative pain-related thoughts and replace them with more positive copingNo
related thoughts.
Integrate and implement new mental, somatic, and behavioral ways of managing pain.
No

No Change

No Change

No Change

No Change

No Change

No Change

Identify and monitor specific pain triggers.

Prognosis
Prognosis Rating of successful
achievement of Goals
Good

Projected Number of Sessions Projected Date for

before Treatment End
Treatment End
8
10/7/2006

% of Critical Objectives
Achieved by Treatment End
70%

Rationale for Prognosis Rating:

Judy is strongly motivated to work on her issues and she has a good support network.

Discharge
Discharge Criteria:

Mood, behavior and thought stabilized sufficiently to independently carry out basic self-care.
Verbalizes names of supportive resources who can be contacted if feeling suicidal/homicidal.
Hallucinations or delusions controlled enough to not interfere with basic self-care.

Competency to manage self-care:

Competency to manage financial resources:
Follow-up care:
Referral Made To:
Placement Recommendation:
Vocational Plan:
Treatment End Date:

Competent
Competent
Outpatient Therapy
Self Care
Return to full-time job

After-care Plan/ Discharge Summary:

Provider Credentials

Primary Treatment Provider

Default Provider

Supervisor
Default Provider

License:

License:

______________________________________________
Treatment Team: Clinical Staff

Default Provider

Requested Amendments
Request Date:

8/7/2006

Section:

Progress

Approved:

Yes

Approve/Deny Date: 8/7/2006

Name: Judy A. Sample

1/26/2016
Reason for Denial:
Person Approving/Denying:
Amendment:

ID: 1
Page #: 10

SSN: 555-55-5555

Birthday: 7/7/1946

Person Requesting:

Date:

Judy Sample

Jongsma, Arthur E (PhD)

Judy wants to point out that she has always been tense and fearful.

Disclosure Authorizations
Patient was provided PHI Privacy Notice: Yes
Patient signed PHI Privacy Acknowledgement: Yes
Patient Has Not Signed but Receipt of Form was Witnessed: No
Date: 8/7/2006

Purpose: Provision of PHI to other professionals

Authorization on File:
Address:

General Notes

Yes

To Whom:

Bill Allen
City: Fastoo

What Disclosed: All Protected Health Information except

Psychotherapy Notes
Agency: Fastoo CMH
State: MI
ZIP: 49525