Free Therapy Progress Summary Medical Report Template
Therapy Progress Summary Medical Report
Patient Information
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Patient Name: |
John |
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Patient ID: |
123456789 |
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Date of Birth: |
January 1, 2050 |
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Gender: |
Male |
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Contact Information: |
123-456-7890 |
Diagnosis
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Primary Diagnosis: Major Depressive Disorder (ICD-10: F33.1)
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Secondary Diagnoses: Generalized Anxiety Disorder (ICD-10: F41.1)
Treatment Goals
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Increase Daily Functioning: Achieve a consistent routine of daily activities (e.g., work, exercise, social interactions).
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Reduce Symptoms of Depression: Decrease the Patient Health Questionnaire (PHQ-9) score from 18 to below 10.
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Enhance Coping Skills: Develop effective coping strategies for managing anxiety and stress.
Progress Summary
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Date of Sessions: September 1, 2060 - October 1, 2060
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Number of Sessions Completed: 6
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Progress Towards Goals:
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Goal 1: John has successfully established a daily routine, reporting regular participation in work and social activities three times a week. He has also started a morning walking regimen.
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Goal 2: Initial PHQ-9 score was 18; after six sessions, his score has improved to 12, indicating a reduction in depressive symptoms.
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Goal 3: John has learned and implemented at least three coping strategies, including mindfulness meditation and cognitive restructuring, and reports using these techniques daily.
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Clinical Observations
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Patient Engagement: John is actively engaged during sessions, contributing insights into his feelings and behaviors, which enhances the therapeutic process.
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Strengths: John demonstrates resilience and a willingness to learn. He has shown notable improvement in expressing his thoughts and emotions.
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Challenges: He occasionally struggles with negative self-talk, particularly in social situations, which we are addressing in therapy.
Recommendations
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Continued Therapy: Recommend ongoing therapy sessions once a week for the next month to continue progress and refine coping strategies.
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Adjustments to Treatment Plan: Introduce group therapy sessions focused on social skills to help John feel more comfortable in social settings.
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Additional Referrals: Consider a referral to a psychiatrist for evaluation of medication options if symptoms do not continue to improve.
Next Steps
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Follow-Up Appointment: Scheduled for October 9, 2060, at 3:00 PM.
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Expected Duration of Treatment: The estimated duration of ongoing therapy is 3-6 months, depending on progress.
Therapist Signature
[Your Name]
Therapist
