DATE OF SERVICE: MM/DD/YYYY
This is a 60-minute established psychodynamic psychotherapy visit.
DIAGNOSES:
AXIS I: Major depressive disorder, recurrent, severe; anxiety disorder, not otherwise specified.
AXIS II: Deferred.
AXIS III: History of hypertension.
AXIS IV: Divorced, living alone, single, family conflict and job difficulties.
AXIS V: Global Assessment of Functioning 70.
INTERIM HISTORY: The patient returns today for established weekly visit. He is scheduled to meet with this examiner as well as supervising psychiatrist, who arrives after the visit is underway for 15 minutes and stays for the remainder of the visit. The patient is on time, having come in the rains, is pleasant and easily engageable.
We are now in the treatment phase of psychodynamic psychotherapy and things discussed today surround the patient’s anxiety, impending conflict, and his difficulty trusting his instincts, particularly after the fact, which stems back to his family conflict as a child but which he has also carried forward, and it impacts his adult relationships and job performance.
The patient shares more this week than he has previously, possibly due to the presence of supervising psychiatrist. He again reveals it is difficult for him to follow his own train of thought; however, finds it helpful to talk through his anxiety and try to understand where it comes from and how he can regain control.
MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic male, appearing stated age, with black hair, well groomed, casually attired, coming from work and wet from the rain with good eye contact, spontaneous fluent speech, euthymic mood with congruent affect, upbeat and bright. Thought process linear and goal directed. Thought content negative for any suicidal or homicidal ideation. No harmful intent or plan. No auditory or visual hallucinations, no signs of responding to internal stimuli or formal thought disorder. Estimated intelligence is above average with good insight and fair judgment.
ASSESSMENT: The patient is a (XX)-year-old divorced Hispanic male with past psychiatric history of depressive disorder, recurrent, severe and anxiety disorder, not otherwise specified, who presents for established weekly psychodynamic psychotherapy visit with supervisor psychiatrist present, continuing in the treatment phase of therapy and identifying patterns of anxiety and negative thoughts that influences feeling and behavior.
PLAN: We will continue to meet weekly at 5 p.m. on Wednesdays. Our next appointment is scheduled for MM/DD/YYYY at 5 p.m. The patient agrees to contact this examiner with nonurgent issues only by voice mail and to seek emergency mental health services should his personal safety become an issue and to call 911.
He will continue to be followed by Dr. John Doe in the psychopharmacology clinic for his medication prescriptions as well as with primary care provider at the adult primary care clinic.
