Progress-Notes-Cheat-Sheet
Progress-Notes-Cheat-Sheet
Patient Prompts
1. Patient reported
- Feeling
- Experiencing
- struggles with
- Managing
- Overcoming
- anxiety surrounding
- difficulty with
- negative feelings surrounding
- issues with
2. Patient explored
- Thoughts and feelings about
- Past experiences related to
- Connections between
- Barriers to
- Personal beliefs regarding
- Triggers
- core beliefs
- cognitive biases
3. Patient expressed
- Concerns about
- Satisfaction with
- Confusion regarding
- Hopes for
- Fears about
- difficulty with
- resistance
4. Patient demonstrated
- Progress in
- Difficulty with
- Mastery of
- Resistance to
- Improvement in
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5. Patient identified
- Goals for
- Triggers of
- Patterns in
- Strengths of
- Coping mechanisms for
- attachment style of
- struggles with
- past experiences with
- root of
- a connection between
- relationships with
7. Encouraged Patient to
- Practice self-compassion
- Set realistic goals
- Establish healthy boundaries
- Seek social support
- Prioritize self-care
- practice positive self-talk
- utilize thought stopping techniques
- utilize skills of
- communicate with
- build a routine
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8. Provided psychoeducation about
- Cognitive distortions
- Stress management
- Communication styles
- Emotional regulation
- The impact of trauma
- the panic cycle
- depressive episodes
- manic episodes
- affective disorders
- addiction
- parenting styles
- window of tolerance
- mindfulness
- trauma responses
- stages of grief
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11. Facilitated discussion on
- Personal values
- Family dynamics
- Cultural considerations
- Conflict resolution
- Interpersonal effectiveness
- mindfulness
- cycle of avoidance
- the panic cycle
- anxiety
- the depression cycle
- coping strategies
- behavioral activation
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15. Patient reflected on
- Past successes
- Personal growth
- Challenges overcome
- Unhelpful thought patterns
- Impact of past events
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20. Explored with Patient
- Ambivalence towards change
- Feelings of shame and guilt
- Impact of stigma
- Frustration with progress
- Fear of failure
- resistance to change
- discrepancy between
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26. Patient gained insight into
- Unconscious processes
- Emotional patterns
- Origins of symptoms
- Interpersonal dynamics
- Cognitive distortions
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32. Discussed with Patient
- Importance of consistency in attendance
- Benefits of medication adherence
- Role of self-compassion in recovery
- Strategies for crisis management
- Impact of sleep and nutrition on mental health
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38. Patient increased
- Emotional awareness
- Coping skills repertoire
- Social support network
- Self-confidence
- Level of assertiveness
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44. Patient attended to
- Physical health
- Mental health
- Emotional well-being
- Social connections
- Spiritual needs
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50. Patient and therapist reviewed
- Overall progress made in therapy
- Accomplishments and areas for continued growth
- Therapeutic milestones reached
- Strategies for maintaining gains
- Plan for ongoing support and resources
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57. Patient demonstrated capacity for
- Emotional growth
- Self-reflection
- Taking personal responsibility
- Empathy towards others' experiences
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65. Patient demonstrated resilience in
- Handling setbacks
- Facing difficult emotions
- Overcoming personal challenges
- Pursuing therapeutic goals despite obstacles
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Therapist prompts
1. Therapist explored client's
- Early childhood experiences
- Attachment styles
- Core beliefs and schemas
- Trauma history
- Cultural influences
- Preconceived notions of therapy
- Family of origin
- Parenting Style
- sense of self
2. Therapist introduced
- Cognitive-behavioral techniques
- Solution-focused approaches
- Psychoanalytic concepts
- Acceptance Commitment Therapy
- Dialectical Behavioral Therapy
- Mind-body interventions
- Narrative therapy techniques
- Yoga Nidra/Body Awareness
- Mindfulness Meditation
- the concept of Wise Mind
- Internal Family Systems
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5. Therapist assisted client in
- Identifying and challenging cognitive distortions
- Reframing negative thinking patterns
- Cultivating self-acceptance and self-esteem
- Exploring identity and self-discovery
- Developing self-identity outside of roles
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11. Therapist encouraged client to
- Practice self-compassion and self-forgiveness
- Challenge perfectionism and unrealistic expectations
- Embrace vulnerability and authenticity
- Engage in self-exploration and self-expression
- Foster a sense of purpose and meaning
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17. Therapist explored client's
- Internalized beliefs about mental health
- Experiences of stigma and discrimination
- Coping with societal expectations and pressures
- Cultural factors influencing help-seeking behaviors
- Advocacy for mental health rights and awareness
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23. Therapist explored client's
- Fears of dependency or abandonment
- Desire for independence and autonomy
- Attachment needs and attachment styles
- Trust in the therapeutic relationship
- Transference and countertransference dynamics
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29. Therapist discussed with client
- Strategies for managing treatment resistance
- Addressing therapeutic ruptures and repairs
- Exploring and reframing negative therapeutic experiences
- Building trust and rapport in the therapeutic relationship
- Collaborative decision-making in the therapy process
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35. Therapist encouraged client to
- Seek community resources and support groups
- Engage in volunteer work or altruistic activities
- Advocate for mental health awareness and destigmatization
- Pursue hobbies or interests outside of therapy
- Engage in activities that bring joy and fulfillment
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41. Therapist discussed with client
- The therapeutic process and potential challenges
- Collaborative decision-making in treatment planning
- Integration of therapy goals with personal values
- Flexibility in adapting treatment approaches
- Reinforcement of progress and growth in therapy
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47. Therapist discussed with client
- Therapeutic homework assignments and their purpose
- Application of therapy insights to real-life situations
- Reviewing progress on specific therapy goals
- Reinforcing positive changes and adaptive behaviors
- Exploring challenges or barriers in completing assignments
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55. Therapist implemented psychodynamic approaches to
- Explore unconscious processes and conflicts
- Examine the impact of early experiences on current functioning
- Foster insight into interpersonal dynamics
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64. Therapist integrated play therapy techniques for children to
- Facilitate emotional expression and exploration in a safe and engaging manner
- Encourage communication and understanding of emotions
- Develop social and problem-solving skills
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