Free Download Therapy Note Template with Most Complete Sections
Recording medical history, including the therapy notes is essential for future medication. If you visit the clinic so often, you will appreciate this document because, in the future, the therapist or physician will need this for accurate treatments, recall as well as collaboration.
For any physical and mental health experts, a therapy note template is the first thing to have for helping them record the patient’s health history. Besides, the templates are mostly easy to customize and completed with narrative segments.
Here are some tips to consider to make effective therapy notes.
- Demographic information – Begin with the most basic things like name, sex, age, race and so on. This also includes the current living situation, job, relationship status, and any other basic information.
- Complaint – It’s very helpful to write down the client’s complain. It doesn’t have to be complete, but you can record the main point and summarize it to make it more efficient.
- Symptoms – Certain factors like client’s reactions and your clinical assessments play an important role in diagnosing the diseases as well as deciding the best treatment. This is the main foundation to be recorded in any type of therapy note.
- Safety Concerns – Some clients might comment on things that lead to self-harm which you need to record too. It will give you a strong reason to provide urgent intervention by another professional.
- Medications – There are many pharmaceuticals can affect mental health. It is important to closely pay attention to this case. Keep in mind to update this section oo and ask your client if they are consuming certain medication or not.
- Symptom History – Get the full history of your client’s struggle such as in various job, life change and relationship. Do this approach to know the main trigger that leads them to the current condition.
- Current Mental Status – This needs to be done carefully to observe your client and analyze the relevant aspect. Make sure you take notes thoroughly to provide more comprehension.
- Narrative of Events – You might need to have an appointment with the clients and observe why they need schedules or even why they miss the appointment.
- Session Recaps – Make sure you also make a summary in a brief recap in two formats; SOAP and PAIP. Both are the most common notes you have to follow. The SOAP stands for Subjective – Objective- Assesment and Plan. Meanwhile, the PAIP stands for Problem – Assesment – Intervention, and Plan.
- Discharge Summary – This point will talk about the quick review of the client’s association with your service. This will give a quick review about the demographic information, therapy targets and initial assessment along with the necessary intervention and follow up.
Our therapy note template gives you the most complete sections to ease you making a report and record the clients’ physical and mental history so in the future it can be used for another purpose that requires therapy report. This is important to have a clear section in the report so everyone can understand and learn it thoroughly in the purpose of having a good treatment.
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