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****Psychiatric Therapy Note***These assignments allow the student to learn how
****Psychiatric Therapy Note***These assignments allow the student to learn how to do distinct types of notes that the PMHNP might be called upon to write during their career. Therapy notes are meant to be brief and often follow the Data, Assessment, Plan (DAP) format. D- Data= This section should include what behaviors were observed during the therapy Focus of the session, topics discussed, and what the client tells you about the problem and symptoms. Relate to diagnosis, use quotes, and include specific details (frequency, severity, duration, etc.) and impact on functioning. Include the status of risk issues, if any (substance abuse, danger to self/others, etc.) A- Assessment= Therapist thoughts and assessment of client progress and the medical necessity for treatment. Assess barriers to progress or regression. Describe unusual appearance, thinking, and/or behavior. Note changes to diagnosis. P- Plan= What did you do? What do you plan to do? Include therapist in-session Interventions (ex. “Cognitive reframing, “taught progressive relaxation”), referrals, and homework assigned. Include reminders for planned actions for future sessions and changes to the treatment plan (ongoing lack of progress should lead to a change in the treatment plan. Important: Therapy notes are not a part of the regular patient chart. However, they should be released to patients if it is determined that the contents could be psychologically harmful.
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