Date: [Date of Session]
Patient: [Patient Name], [age] years old, [male/female]
Session Overview:
1. Objectives of the Session:
- [State the primary goals or objectives for this session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
2. Review of Previous Session:
- Progress: [Summary of progress made since the last session, including any achievements or changes] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Challenges: [Any difficulties or obstacles encountered since the last session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
3. Patient's Report:
- Current Issues: [Patient’s current concerns or issues related to their mental health, as discussed in the session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Mood and Emotions: [Patient’s self-reported mood and emotions during the session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Behavioural Observations: [Any notable behaviours observed during the session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
4. Cognitive Interventions:
- Identified Cognitive Distortions: [List of cognitive distortions identified during the session, such as all-or-nothing thinking, catastrophising, etc.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Challenging Thoughts: [Summary of the techniques used to challenge and reframe distorted thoughts] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- New Cognitive Strategies: [New cognitive strategies or skills introduced during the session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
5. Behavioural Interventions:
- Behavioural Experiments: [Details of any behavioural experiments or assignments discussed or assigned during the session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Skill Development: [Skills or techniques focused on during the session, such as relaxation techniques or problem-solving strategies] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
6. Homework Assignment:
- Tasks Assigned: [Description of any homework tasks or exercises assigned to the patient for completion before the next session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Purpose: [The purpose or goal of the assigned homework] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
7. Plan for Next Session:
- Topics to be Addressed: [Overview of topics or issues planned to be discussed in the next session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
- Goals: [Goals set for the next session] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
"Thank you,"
"[Clinician's Title, Name & Surname]"
"[Clinician's specialty]"
"Practice number: [Clinician's Practice Number]"
(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 included 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 section blank.)