Standard Progress Note
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What is the "Overall Notes" box for in the Standard Progress Note. What kind of information goes in that box?
Thank you
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And I would love to hear about the meanings of the terms in the Standard Progress Note Observation section.
What do others understand by the terms in the Observations section (some are obvious but they all warrant conversation)? I would love an expanded conversation about them. Perhaps there is a manual out there somewhere, but I could not find it.
Cognitive Functioning:
Oriented/Alert
Disorganized
Preoccupied
CircumstantialAffect:
Appropriate
Inappropriate
Labile
Constricted
Blunted
FlatMood:
Euthymic
Depressed
Dysphoric
Anxious
Angry
EuphoricInterpersonal:
Interactive
Intermittently Interactive
Guarded
Withdrawn
HostileFunctional Status:
Intact
Impaired
Variably Impaired -
Hi Reginald, the Standard Progress Note is a Progress Note Template, within SimplePractice, that you can use when entering a Progress Note for a client's appointment. You can add a Psychotherapy Note to the bottom of the Progress Note if you want to mention something that you don't want included in the client's official medical record. There are also Administrative Notes and Chart Notes in SimplePractice, you should be able to enter both in any clients' files. Administrative Notes are like post-it notes that appear at the top of the client's file. They're not included in a client's official medical record, but are used to communicate things with other staff members or as an internal reminder for you. Chart Notes aren't attached to any particular date of service, but are part of the client's medical record.
Here's more on all the notes you can enter for your client:
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