DAP Progress Note Template

Client/ID: Liam O'Connor (MRN: 492-810-34)

Therapy Provider: Dr. Sarah Jenkins, Clinical Psychologist

Session Date: 24/10/2023

Start and Finish Time: 14:00 – 14:50 AEDT

Data

• Client reported ongoing work-related stress and initial insomnia (taking > 2 hrs to fall asleep, 4 nights/wk). Client stated, "I cannot switch my brain off after logging off work." Client also noted good adherence to escitalopram (Lexapro®) 10 mg PO daily, prescribed by his GP.

• Clinician observed client to be A&Ox4. Mood reported by client as "anxious"; affect observed by clinician as constricted but congruent. Speech normal in rate, rhythm, and volume. Thought process linear and goal-directed; no delusions or hallucinations observed.

• Clinician observed client to be casually dressed, well-groomed, with good hygiene. Appeared mildly fatigued with dark circles under eyes.

• Clinician provided psychoeducation on the CBT model of insomnia (CBT-I) and sleep hygiene. Clinician guided client through a 10-minute progressive muscle relaxation (PMR) exercise and introduced cognitive restructuring using a thought record for workplace perfectionism.

• Client engaged cooperatively with the PMR exercise, stating afterward, "My shoulders feel noticeably less tense." Client was receptive to the thought record concept and actively identified two common cognitive distortions (catastrophising and all-or-nothing thinking).

• DASS-21 administered today: Depression = 6 (Normal), Anxiety = 12 (Moderate), Stress = 22 (Moderate). K10 score = 24.

Assessment

• F41.1 Generalised Anxiety Disorder (stable, no changes to diagnosis).

• Risk assessment conducted by clinician: Client explicitly denied current suicidal ideation, intent, or plan, and denied history of self-harm or homicidal ideation. Clinician assessed acute risk as low.

• Client is demonstrating moderate progress toward treatment goals, evidenced by a 4-point reduction in DASS-21 Stress score since initial intake and consistent engagement with in-session somatic exercises.

• Maladaptive perfectionistic beliefs regarding work performance and persistent evening rumination interfering with sleep onset require ongoing targeted intervention.

Plan

• Integrate formal CBT-I stimulus control protocols into the current CBT treatment plan to directly address sleep onset latency.

• Goal: Reduce sleep onset latency to < 30 mins. Intervention: Implement stimulus control and a 30-minute pre-bedtime wind-down routine, alongside ongoing cognitive restructuring.

• Client to complete a daily sleep diary and record at least 3 automatic negative thoughts using the CBT thought record worksheet over the next fortnight. Client to practice PMR audio track nightly at 21:30.

• Referring back to GP (Dr. A. Patel) at 6-week mark for routine MHTP review and medication follow-up.

• Client to monitor the link between evening screen/email use and physiological arousal, and practice accepting "good enough" completion for non-urgent daily work tasks.

• 07/11/2023 at 14:00 AEDT, Clinic Room 3 (In-person).