Patient: William Lance Mental Health Progress Note Date: 09/21/XX… Patient: Wil

Patient: William Lance Mental Health Progress Note Date: 09/21/XX… Patient: William LanceMental Health Progress NoteDate: 09/21/XXLength of service: 50 minutes of individual psychotherapyNotes: The patient has continued to work on “Oceans of Emotions” workbook to help identify and understand her emotions better. Patient has worked on short- and long-term goals; socially and emotionally. She denies any difficulty in school with organization or concentration. She does endorse wanting more friends.Mental Status Examination: Alert, casually groomed, wearing jeans and fleece; cooperative, good eye contact.Speech: Normal. Thought Process: Linear. Thought content: Appropriate. Mood: “Fine.” Affect: Somewhat anxious at times. Insight and Judgment: Fair/good. Attention: Fair. Changes to Medications Since Last Visit: None. No side effects reported. Good compliance. Current Medications: Risperdal 1 mg TID. Adderall XR 30 mg q am, Adderall 15 mg at 2 pm, Celexa 5 mg q day Diagnoses:1) ADHD; 2) Reactive adjustment disorder with anxietyPlan: 1) Continue current meds; 2) Mother to meet with therapist for family therapy; 3) Insurance has approved up to eight more visits of supportive therapyTreatment Plan Goals: 1) Decrease mood dysregulation; 2) decrease anxiety; 3) improve socialization; 4) improve self-esteemWhat is the PCS Code? Health Science Science Nursing HIM-2020 MISC Share QuestionEmailCopy link Comments (0)

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