Patient information
Name: [insert client’s full name] (only include client’s full name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date of birth: [insert client’s date of birth] (only include date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Session date: [insert session date] (only include session date if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Session duration: [insert session duration] (only include session duration if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Behavioral goals
[describe the behavior goals targeted in the session] (write as a short paragraph or concise summary; include only specific, measurable behavior goals drawn from the treatment plan or behavior intervention plan if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Session overview
Antecedent: [describe the antecedents observed during the session] (write in brief, clear sentences or phrases; only include if antecedents have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Behavior: [describe the client’s behavior during the session] (write in brief, clear sentences or phrases using objective language; only include if behavior has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Consequence: [describe the consequences that followed the behavior] (write in brief, clear sentences or phrases; only include if consequences have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Interventions used
Behavioral strategies: [outline the behavioral strategies implemented in the session] (write in full sentences or short paragraph format; only include if behavioral strategies have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Reinforcement: [describe reinforcement methods applied] (write in full sentences; include only if reinforcement has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Prompting: [describe any prompting procedures used] (write in full sentences or phrases depending on context; only include if prompting has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Prompt fading: [describe prompt fading methods if applied] (write in full sentences; only include if prompt fading has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Data collection
Frequency: [report frequency data collected during the session] (enter brief numeric or categorical data as applicable; only include if frequency data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Duration: [report duration data collected during the session] (enter brief numeric or categorical data; only include if duration data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Intensity: [report intensity ratings or descriptions collected during the session] (enter as brief numeric score or descriptor; only include if intensity data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Progress and observations
Progress toward goals: [summarise client’s progress toward treatment goals] (write as a brief paragraph; only include if progress is mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Strengths: [note observed client strengths during the session] (write in full sentences or bullet-style phrases depending on context; only include if strengths are mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Areas for improvement: [note challenges or skill deficits observed during session] (write in full sentences or bullet-style phrases depending on context; only include if areas for improvement are mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Collaboration
Communication with caregivers: [document any communication with caregivers during or regarding the session] (write as brief paragraph or summary line; only include if caregiver communication has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Collaboration with other professionals: [document interactions with other providers or professionals] (write as brief summary sentence; only include if collaboration has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Recommendations
Adjustments to treatment plan: [note any proposed changes to the current treatment plan based on observations] (write in full sentences; only include if adjustments are mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Homework or assignments: [specify any tasks, practice activities, or assignments given for outside the session] (write in sentence format; only include if homework or assignments are mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Healthcare provider’s information
Name: [insert provider’s name] (only include provider’s name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
ID number: [insert provider’s ID number] (only include provider’s ID number if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Contact details: [insert provider’s contact information] (only include provider’s contact details if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date: [insert date of completion] (only include date if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
