Please see attachment for instructions
The purpose of these assignments are to allow the student to learn how to do various types of notes that the PMHNP might be called upon to write in the course of their career. Therapy notes are meant to be brief and often follow the Data, Assessment, Plan (DAP) format.
D- Data= This section should include what behaviors were observed during the therapy and anything that might be pertinent to how you want to proceed with the therapy treatments.
A- Assessment= What is your assessment of the behaviors and what do they mean in relation to the therapy you are using. What do you think the client’s actions mean? Are the clients progressing toward the goals?
P- Plan= Record the treatment plan for your patient.
Example:
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D- Met with M for 45 minutes via virtual session. Today she is reporting that she is in training at Amazon and it is going well. She reports that she is anxious about the 2 hour bus ride and that her work hours are overnight, so she is coming/ going in the dark. She is also worried about having too many badges to scan at work and afraid she will ‘mess up’. She states she was anxious about finding her way in the large building but there are markings on the floor to guide her and after a few days she is feeling more at ease. She is not wanting to return to community college now that she has found this employment that is not a seasonal job. A- Monica has made improvement in her anxiety symptoms and seems quite proud of her progress and accomplishments with the new job. We discussed her past patterns of putting pressure on herself and over thinking. She has already overcome one obstacle by navigating the large building and can use the same skills for the other stressors that cause her anxiety at this new job. P- HW: Breathing and mindfulness techniques when feeling anxious. Speaking up politely if feeling overwhelmed at new job. Talk with grandmother about not going back to college. Next session in 1 week. |
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