This NovoNote template is designed to summarise a session between a mental health clinician and a client using the DAP (Data, Assessment, and Plan) note format.
Each section below outputs a single paragraph of less than six sentences.
Data:
Assessment:
Plan:
Data:
Mary reported her mood as “up and down” this week, with particular difficulty managing work-related stress following a critical meeting with her supervisor. She described experiencing increased anxiety symptoms, including racing thoughts, difficulty sleeping, and tension headaches occurring 4-5 times this week. Mary appeared anxious during session with rapid speech, fidgeting hands, and intermittent eye contact. She discussed feeling overwhelmed by multiple competing deadlines and reported using avoidance strategies, including procrastination and social withdrawal. Mary noted she completed her thought record homework twice but found it challenging to identify alternative thoughts.
Assessment:
Mary continues to demonstrate symptoms consistent with generalised anxiety disorder, with work-related stressors exacerbating her presentation this week. Her anxiety is maintained by catastrophic thinking patterns about performance and tendency to avoid tasks when feeling overwhelmed, creating a cycle of increased stress and reduced productivity. Mary shows good insight into her patterns but struggles with motivation to implement coping strategies when anxiety is elevated. She engaged well with cognitive restructuring during session and expressed willingness to continue practising skills despite finding them initially difficult. Within a CBT framework, Mary is making gradual progress in identifying automatic thoughts but requires continued support in generating balanced alternatives.
Plan:
Provided psychoeducation about anxiety cycle and relationship between avoidance and increased distress. Practised cognitive restructuring techniques in session using Mary’s recent work situation as example, identifying catastrophic predictions and developing more balanced perspectives. Introduced graded task planning to address procrastination and reduce overwhelm from competing deadlines. Mary agreed to continue daily thought records and break down one large work project into smaller steps this week. Next session scheduled for 22 March 2024 at 2:00 PM to review progress with cognitive techniques and task planning.
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