Therapy Progress Summary Medical Report

Therapy Progress Summary Medical Report

Patient Information

Patient Name:

John

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Male

Contact Information:

123-456-7890

Diagnosis

  • Primary Diagnosis: Major Depressive Disorder (ICD-10: F33.1)

  • Secondary Diagnoses: Generalized Anxiety Disorder (ICD-10: F41.1)

Treatment Goals

  1. Increase Daily Functioning: Achieve a consistent routine of daily activities (e.g., work, exercise, social interactions).

  2. Reduce Symptoms of Depression: Decrease the Patient Health Questionnaire (PHQ-9) score from 18 to below 10.

  3. Enhance Coping Skills: Develop effective coping strategies for managing anxiety and stress.

Progress Summary

  • Date of Sessions: September 1, 2060 - October 1, 2060

  • Number of Sessions Completed: 6

  • Progress Towards Goals:

    • 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.

    • Goal 2: Initial PHQ-9 score was 18; after six sessions, his score has improved to 12, indicating a reduction in depressive symptoms.

    • Goal 3: John has learned and implemented at least three coping strategies, including mindfulness meditation and cognitive restructuring, and reports using these techniques daily.

Clinical Observations

  • Patient Engagement: John is actively engaged during sessions, contributing insights into his feelings and behaviors, which enhances the therapeutic process.

  • Strengths: John demonstrates resilience and a willingness to learn. He has shown notable improvement in expressing his thoughts and emotions.

  • Challenges: He occasionally struggles with negative self-talk, particularly in social situations, which we are addressing in therapy.

Recommendations

  • Continued Therapy: Recommend ongoing therapy sessions once a week for the next month to continue progress and refine coping strategies.

  • Adjustments to Treatment Plan: Introduce group therapy sessions focused on social skills to help John feel more comfortable in social settings.

  • Additional Referrals: Consider a referral to a psychiatrist for evaluation of medication options if symptoms do not continue to improve.

Next Steps

  • Follow-Up Appointment: Scheduled for October 9, 2060, at 3:00 PM.

  • Expected Duration of Treatment: The estimated duration of ongoing therapy is 3-6 months, depending on progress.

Therapist Signature

[Your Name]

Therapist

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