The presenting problem is the focus of treatment and the mental health diagnosis should be based upon this. Each client presents with unique nuances as to how a problem behaviorally reveals itself. It is important to identify and list the symptoms of the problem in a way that would justify the DSM diagnosis.
Patient reported she has been feeling depressed for the past three weeks. She reported feeling a constant heavy sadness, having low energy, having little to no appetite, and sleeping excessively. She reported she thought about suicide several times a week, but denied a having a plan.
The goal, objective, and intervention must be based on the problem/diagnosis and be specific, quantifiable and observable and applicable to the client’s needs and abilities. The client should be able to see how working towards the goal will help to resolve the stated problem. In measuring the goal and intervention, it is helpful to include numbers, but avoid using percentages(%). Example: Patient will reduce suicidal thoughts to one or less time per month.
Pt will increase energy level to participate in enjoyable activities at least four days per week.
Pt will reduce amount of time spent sleeping to 8 hours per day at least five days a week for one month.
Short term action steps that the client will do to accomplish their goals. These are simple, straightforward, measurable, achievable, realistic and timed framed. As with goals, they are also specific, quantifiable, and observable. Example: Patient will attend 8 individual counseling sessions once per week for 60 minutes.
Patient will take medication as prescribed by psychiatrist, keeping follow up medication evaluation appointments and reporting side effects as they occur. Patient will identify three enjoyable activities that help to reduce her sadness. XX will log the use of these activities in her journal.
In therapy sessions, patient will identify 6 recurrent negative thoughts that precede suicidal thoughts and replace them with more positive, adaptive thoughts
Interventions are the actions of the clinician designed to help the client complete their objectives. They should be consistent with the goals and must include duration. All services provided to the patient should be included in this section. To be precise for the coders, you should also include CPT codes to describe. Example: SW will provide group therapy once per week for 90 minutes
SW will provide individual therapy for 60 minutes 1 x per week and utilize cognitive behavioral techniques to assist patient in stabilizing symptoms
SW will link patient with psychiatric resources for medication as needed for the next 6 months.
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