Progress Note Phrases

Client arrived on time to scheduled appointment.

Client did not arrive on time to scheduled appointment, client was –minutes late.
Client did not present with signs or symptoms of suicidal ideation or homicidal ideation, no safety
plan is warranted at this time.
Client was cooperative and provided needed information to complete
Client called to reschedule appointment
Completed self-response inventories to gauge client’s symptoms of
Started mental health evaluation for immigration petition.
Reviewed treatment plan with client; client made suggestions, treatment plan will be updated.
Client reviewed and accepted treatment plan.
Clinician was asked to come into session for crisis management by
..indicated client was demonstrating signs of distress as evidenced by

Interventions and service detail:

Acknowledged attempts to Built rapport by Developed positive
affirmations
Actively listened to client as Built trust through
Discussed
Addressed clients concerns Challenged beliefs/thoughts
Discussed current stressors
Addressed worries/fears Clarified/sought
and their affect on client’s
clarification
Aided in developing insight daily functioning.
Commended
Allowed client to ventilate Discussed patterns of
Connect comments about
Amplified Directed/redirected
Confronted
Affirmed Educated
Contracted for
Asked about Elicited
Cued
Assessed risk Encouraged
Deescalated
Assessed for Encouraged verbalization
Developed a contingency
Assigned task Engaged client in play
plan
Assisted client in/with Empathically responded
Developed behavioral
Attempted to generalize program Established boundaries
Established connections Normalized clients feelings Supported
between
Praised Taught coping skills
Examined
Probed Titrated exposure to
benefits/consequences
traumatic events to avoid
Processed
Explained re-traumatization
Problem solved
Explored Used directive comments to
Provided feedback
Explored self-defeating life Utilized desensitization
patterns and beliefs Provided a corrective social
Utilized
experience
Explored options imagery/visualization
Provided client with
Evaluated Utilized assertiveness
unconditional positive
training
Facilitated regard
Utilized relaxation training
Focused Provided psychoeducational
information regarding Utilized humor
Gave feedback
Questioned Utilized empathic
Guided
understanding
Reassured
Helped client develop
Utilized silence
Redefined
Helped client to express
Validates clients point
anger constructively Reflected
Verbalized
Helped client redefine Refocused
Worked on behavioral
Highlighted consequences Reframed
program
Identified Reinforced
Identified themes Responded to
CLIENT’S RESPONSE
Identified triggers Restated TO INTERVENTION,
PROGRESS TOWARDS
Increased awareness Reviewed GOALS &
Inquired about Reviewed events from OBJECTIVES, STATUS
previous week OF SYMPTOMS &
Informed interpreted FUNCTIONING
Reviewed limits
Investigated
Recommended
Led client in practicing Client reports
Role played
Listed client’s Client reports somatic
Set limits complaints in the form of
Modeled
Summarized Client states
Monitored
Client is currently working
on
Client’s initial complaint of
Client is making progress
towards
Client is lacking progress
towards
Client has made significant
changes to
Client seems to be lacking
improvement due to
…as evidenced by
Client dissociated briefly
while discussing
Client seemed to have a
physiological reaction when
discussing
Client disclosed recurrent
memories/nightmares of
trauma
Client expressed a pattern
of
Client expressed concerns
Client has experienced
intense distress when
discussing
Client is unable to recall
certain aspects of traumatic
event
Client continues to
experience persistent
negative
beliefs/expectations about
self
Client continues to blame
self/others for causing
traumatic event or resulting Follow up with
consequences.
Follow up at next
Client reports loss of appointment regarding
interest in previously
Next appointment
enjoyable activities.
scheduled for
Client reports feelings of
Prepare for
Client reports reactivity in termination/discharge at
the form of (irritability, next session.
aggression, self-destruction,
Referral made to
reckless behavior,
hypervigilance, problems Research referrals for
with concentration, sleep
disturbance) Research
Client continues to employ Revision of goals warranted,
–as a defense mechanism in will review at next session.
order to avoid Treatment/service goals
Client continues to make remain appropriate.
SMART goals for self Titrate exposure to
throughout week traumatic events in order to
Client continues to make avoid re-traumatization
plans for the future during mental health
evaluation.
Client continues to avoid
making plans for the future
PLAN
Client was assigned
Client will contact clinician
to schedule follow up
appointment.
Clinician will contact
Collateral meeting needed
with
..to verify
Continue working on
treatment plan and make
adjustments prior to
finalizing with client.