CBT notes with clinical review example
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Authors: |
Angela Jones (Senior CBT Therapist) |
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Date: |
16/07/2024 |
As a registered health professional, Vita Health Group will need to make treatment notes about your condition. These notes constitute a medical record, and as such we are legally obliged to store them confidentially for up to 8 years, after which they will be destroyed.
Notes are stored electronically in line with current data protection regulations and healthcare governing body guidance. The data may be used for audits and statistical analysis, but it is not possible to identify anything about you personally.
For further information on our data protection policy, please visit https://www.vitahealthgroup.co.uk/data-protection-policy/
Consent
We may also provide reports about your condition and treatment to Healthcare Professionals involved in your care, such as your GP. Do you give your consent that I can contact your GP about these difficulties if I think it would help?: *
Yes
×
If we are concerned for your safety at any time during your treatment, this would be discussed with you and we will request your consent to contact your GP or other services. In the event that you do not consent, we may still go ahead if we feel that you are risk to yourself or someone else.
Treatment Session Notes
Patient First Name: James
Patients Last Name: Smith
Date of Session: 22/05/2024
Session Number: 4
Treating Clinician: A Therapist
Treatment Type: CBT
Treatment Modality: * CBT
Current Pathway: * In Treatment
Current Work Status: * Full duties
Primary Working Diagnosis/Primary Presentation: * Depression
Agenda: *
- MDS review
- Risk review.
- Review of home task
- Introduce thought challenging.
- Set home task.
- Feedback on session.
Review In-between session:
James was asked to keep a thought record and identify unhelpful thinking habits.
James completed this successfully and gathered thoughts such as: “I am no good at my job and will get sacked” which brought about feelings of depression and hopelessness, he also identified “All of my colleagues are judging me” which for him lead to feelings of anxiety.
James was able to label his thoughts as ‘catastrophising’ and ‘mind reading’.
On reflection James was able to see the links between his thoughts and emotions.
Content of Session: *
MDS review: James’s scores on the PHQ9 and GAD7 have remained the same since last session. We explored this further, and this appears to be an accurate reflection.
Today I introduced thought challenging to James, using the 7-column thought record.
We used a thought from his home task to challenge in session today, please see below example:
Situation: sent a work email with a spelling mistake.
Emotion: hopeless (80%), depressed (80%).
Thought: “I am no good at my job and I will get sacked”.
Evidence for: James was not able to identify any evidence to support the thought.
Evidence against the thought: 1) It was a minor spelling mistake. 2) I sent the email a week ago and my manager has seen it but not called me into his office to discuss. 3) I have recently had a good annual appraisal.
Challenged thought: “I may have made a minor mistake but that does not mean I am no good at my job, everyone makes mistakes”.
Emotion: hopeless (0%), depressed (0%).
James reported finding the above exercise “really helpful” and “interesting”. James was able to reflect on the biased nature of his thoughts and he could see the benefit of looking at factual evidence.
We used this challenged thought and linked it back into the formulation (Beck formulation). James was able to see how his negative automatic thoughts are driven by his core beliefs and rules for living.
Session feedback: James reported feeling “hopeful” after today’s session, he said that he is starting to see how he can gain some control over his negative thoughts.
Treatment Plan:
We are using Becks cognitive model of depression.
We have completed thought psycho education and thought challenging with the view to moving towards working on rules for living and core beliefs. We will incorporate behavioural experiments to test out new rules/beliefs.
Risk Assessment
Please do not use N/A. Please indicate that you have explored this with your client and document their response.
Suicidal Thoughts: *
James scored 0 on PHQ9 Q9. We discussed this further, and James confirmed that he had no suicidal or self-harm thoughts and he felt able to keep himself safe.
Current Plan: *
James confirmed he had no plans to harm himself or end his life.
Access to Means: *
James confirmed that he had not made any preparations or gathered any means by which to harm himself or end his life.
Intent Rating: *
James confirmed he had no thoughts and intent is low.
Self-harm Thoughts: *
James confirmed he had no self-harm thoughts since our last session.
History: *
James has disclosed one historic suicide attempt – please see initial assessment for full details.
Risk Factors: *
There has been no change in risk factors (please see initial assessment for full details)
Current Triggers: *
Triggers remain the same as at initial assessment (work-based stress).
Safeguarding Issues: *
There are no current safeguarding concerns.
Protective Factors: *
James confirmed that his children and his wife remain his protective factors.
Risk Management and Safety Plan: *
James has confirmed if anything was to change, he would reach out to his GP, or NHS 111 (if out if hours).
James has been provided with a safety plan which has been uploaded to his file as an attachment. The safety plan also contains contact details for services such as the Samaritans.
Risk Formulation: *
James presents with one historic suicide attempt (please see initial assessment for further details), this was triggered by several bereavements in a short space of time.
Since this time (7 years ago), James reported he has much hope for the future, especially since he has got married and had children.
James reported not currently experiencing any suicidal thoughts or thoughts to self-harm. He stated that he would reach out to professional services if these thoughts were to re-occur.
Risk Rating: *
Low
Does this clients risk presentation require review by VHG Risk Duty?: *
No
If yes Rationale for risk review: *
N/A
Clinician Requests
Please use this section to complete any additional sessions requests or request for clinical review.
Do you need to request additional sessions: *
No
×
If yes Rationale for additional sessions: *
Request clinical review of case by VHG clinical team?: *
Yes
×
If yes Reason for clinical review: *
Please can I request a clinical review for James.
James has unfortunately been unable to attend 2 of his sessions due to recent health complications, I have discussed this with James, and he is now fully recovered. I have taken this client to my clinical supervisor, and we are both happy (as is James) for the sessions to recommence. I am however aware of the VHG DNA policy, and I wonder if you could review whether you are happy to the sessions to recommence. James is aware of the policy and that I am reaching out to you for advice.