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Progress Note
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CPT CODE
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Participants
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Diagnosis
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Axis I
• • •
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Axis II
• • •
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Axis III - General Medical Condi
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Axis IV
• • •
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Axis V - GAF
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GAF Descriptor
• • •
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SUBJECTIVE
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Pt report of symptoms
• • •
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Comments about symptoms
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Intensity of symptoms
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Comments about intensity
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Suicidality Scale
• • •
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Comments about suicidality
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Thoughts of harming others
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Comments about harming others.
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Self Harm
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Comments about self harm
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Substance Use
• • •
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Comments about Substance use
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Subjective Description/Notes
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OBJECTIVE AND ASSESSMENT
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Session behavior
• • •
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Affect
• • •
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Thinking
• • •
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Orientation
• • •
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Interventions and Techniques
• • •
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Comments on interventions
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Comments on Objective and Assess
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PLAN AND GOALS
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Frequency of treatment
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Plan
• • •
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GOAL PROGRESS
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Goal/Objective
• • •
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Progress
• • •
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Comments on Goals/Plan
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Recommendation
• • •
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Homework
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REFERRALS
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Referral made to:
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BIBLIOTHERAPY
• • •
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Other Readings
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