Depressive symptoms and impairment

(S)        This section describes the client along with their symptoms, behaviors and resulting impairment(s). Only relevant symptoms and behaviors are listed (meaning those that result in impairment).

(I)         This section describes the interventions or what was done in session and justifies the service; for the session you are writing about, you administered, scored and interpreted two measures (BDI-II and FAM-III). Include significant results.

(P)          This section describes your clinical plan; what will you do next with your client?

Here are the samples:

(S)     Client is female who was self-referred to therapy due to depressed mood, anxiety, panic attacks and sleep disturbance. Client’s symptoms impair her occupational and interpersonal functioning.

(I)      Clinician administered, scored and interpreted the Beck Depression Inventory II (BDI-II)

and Family Assessment Measure-III (FAM-III). BDI-II results indicate client falls into the

Severe Range of depression. FAM-III results indicate client likely perceives her family as

a whole and her relationship with her husband as exhibiting weakness in the area of

responding appropriately to changes in the family life cycle along with communications

that may be insufficient, displaced or masked with a lack of mutual understanding.

Client likely perceives her own functioning within the family as exhibiting strength in the

area of flexibility and adaptability to changes in developmental tasks.

(P)     Plan to refer client for a medication evaluation due to severity of depressive symptoms

and impairment. Plan to provide individual therapy in to help improve mood and

occupational/interpersonal functioning

Here is MINE ( I need you to complete it)

(s)         Complete this section

• Clinician administered, scored and interpreted the Beck Depression Inventory II (BDI-II) and Family Assessment Measure-III (FAM-III). BDI-II results indicate client falls into the Mild Range of depression. FAM-III results indicate client likely perceives her family as a whole and her relationship with her brother as offering strength in the field of family relations plus the communication are characterized by sufficiency of information as well as the messages are direct and clear and the mutual understanding is on a high level among the family members plus family’s values are consistent with their subgroup and the larger culture to which the family belong. The client likely perceives her own affective expression within the family as offering weakness in the field of expressing her feelings among the family, the client is facing difficulties to inadequate affective communication involving in sufficient expression, inhibition of emotions appropriate to a situation.

(P)        Complete this section.