Headings
Presenting problems · Diagnosis · Strengths · Goals · Measurable objectives · Interventions · Frequency and duration · Review date
When to use it
Write it after intake and update it at each review period. It turns the diagnosis into goals, measurable objectives and named interventions, which is what payers and auditors check progress notes against. It is a planning document, not a record of one session.
Example
Fictional example
Presenting problems
T.V., 23, graduate student. Contamination fears and handwashing up to three hours a day. Missing lab shifts.
Diagnosis
Obsessive-compulsive disorder, with good insight.
Strengths
Highly motivated, supportive roommate, good understanding of OCD.
Goals
Reduce compulsions enough to attend all lab shifts.
Measurable objectives
Cut washing to under 45 minutes a day within 12 weeks. Lower Y-BOCS from 27 to 16 or below.
Interventions
Exposure and response prevention, weekly 60 minute sessions for 16 weeks. Psychiatry referral for medication evaluation.
Review date
Review at session 8, with Y-BOCS repeated.