Therapy Note
Created by
Michael Lee
Specialty
Psychiatrist
Last edited
10/20/2026
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0 times
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About this template
A reusable therapy-session documentation template for recording the patient’s presentation, concerns, progress, therapeutic topics and interventions. It also covers medications, safety assessment, follow-up communication, billing codes, and care-plan tasks.
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Summary
- Pt (Sarah Jenkins, 34 yo F, DOB: 14/05/1990, MRN: 492-817-33) presented on 24/10/2024 at 14:00 CST for f/u of GAD and MDD. Reports mild improvement in baseline anxiety since last session two weeks ago, though sleep-onset insomnia persists.
- Addressed ongoing occupational stressors and perfectionism. Strengths include high insight and strong treatment engagement; main difficulty remains setting boundaries with management.
Chief Complaint
- "I'm still feeling overwhelmed by my workload and having trouble shutting my brain off at night."
Topics Discussed
- Workplace reorganization, fear of failure, current sleep hygiene routines, and interpersonal boundaries with her supervisor.
- Pt recognized a pattern of over-functioning at work to mitigate anticipatory anxiety; expressed concern that declining extra projects will negatively impact her upcoming performance review.
Interventions Used
- Utilized CBT cognitive restructuring to challenge catastrophic thinking regarding job security, alongside psychoeducation on stimulus control for insomnia.
- Pt actively participated, successfully identifying two cognitive distortions (catastrophizing, all-or-nothing thinking) and generating balanced alternative thoughts.
Medications
- escitalopram (Lexapro®) 10 mg PO daily for MDD/GAD; hydroxyzine pamoate (Vistaril®) 25 mg PO QHS PRN for anxiety/insomnia.
- 100% adherent to escitalopram with no adverse effects. Reports morning grogginess with hydroxyzine if taken after 22:00, limiting use to 1-2x/week.
Assignments and Plan
- Assignments: Complete a daily thought record focusing on work-related triggers; implement a strict 22:30 wind-down routine with no screens.
- Plan: Continue current pharmacotherapy; RTC in 2 weeks (07/11/2024 at 14:00 CST) to evaluate CBT homework and reassess sleep patterns.
Safety Assessment
- Denies SI, HI, or NSSI. No intent or plan. Low acute risk.
- Protective factors include supportive spouse, future-oriented goals, and consistent engagement in care. Reviewed standard crisis resources (988 Lifeline).
Follow-Up Email
- Hi Sarah, great work today exploring how perfectionism impacts your stress levels at work. Before our next visit on 07/11/2024 at 14:00, please practice using your daily thought record when you feel overwhelmed by new tasks, and try starting your screen-free wind-down routine by 22:30 each night. Remember to take your hydroxyzine earlier in the evening if you need it for sleep to avoid morning drowsiness.
- If you have any questions before our next appointment, please message me through the patient portal or call our clinic office at (312) 555-0194. If you experience a mental health emergency, please call 988 or go to the nearest emergency room.
Billing Codes
- ICD-10: F41.1 (Generalized anxiety disorder), F33.1 (Major depressive disorder, recurrent, moderate); CPT: 99214, 90833
To-Dos
- Send electronic refill for escitalopram 10 mg (90-day supply) to Walgreens; upload CBT thought record PDF to patient portal.
- Complete daily thought record, initiate 22:30 sleep hygiene routine, and confirm next appointment via portal.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.