TIME OF VISIT: 8:30 to 9:15 a.m.
SUBJECTIVE: The patient was accompanied to this session by her father. She continues to have a 2-day adjustment period after returning from home visits. Father is concerned that something is going on. He does not understand why. Had a discussion with him about the need for continuity of care. He agreed. The patient would continue in treatment on a regular basis. The patient agreed that she would be willing to participate in treatment. We will continue to work through play therapy to help the patient express any potential concerns that she has.
OBJECTIVE: The patient was calm and cooperative and maintaining good eye contact. Speech within normal limits. No evidence of psychoses. Thought content was focused on the interview questions. The patient’s mood was anxious with congruent affect. The patient was alert and oriented x3. Attention and concentration were fair. Insight and judgment were fair. Memory appears to be intact.
ASSESSMENT: The patient is doing well, not sure what the adjustments seem to be. Hopefully, the issue has to do with a normal transition. Obviously, the father is concerned that perhaps this is too stressful of a process and as a result of the stress there is a change in behavior. We are hoping that we can work with the patient and further discover what the issue is and hopefully will not be of major concern and therefore we can have resolution to it.
DIAGNOSIS: Adjustment disorder (309.9).
PLAN: See the patient in 2-4 weeks.
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TIME OF VISIT: 9:45 to 10:30 a.m.
SUBJECTIVE: The patient returns to treatment and he was able to discuss the anger cycle in significant detail. He is still having some difficulty in terms of chores, particularly doing the lawn, laundry and dishes when assigned. We discussed the detailed behavioral plan with the mother and the patient, they both agreed. He is not aware of his community service hours and it was indicated that he needs to bring a written report about how many hours he has completed. He tested negative for his drug screen, and his father is still out of the house, and he feels that it is better that that happens as he is more comfortable communicating openly with his mother when the father is not around.
OBJECTIVE: The patient was calm, cooperative and maintained good eye contact. Speech was within normal limits. No evidence of psychoses. Thought content focused on the interview questions. The patient’s mood was anxious with congruent affect. The patient was alert and oriented x3. Attention and concentration fair. Insight and judgment fair. Memory appears to be intact.
ASSESSMENT: The patient is stable, did well with recall of the anger cycle. He needs to be more compliant with his mother at home. I am concerned about his oppositional defiant behavior with respect to simple things as household chores. The patient behaving in such a manner while he is on probation is a concern. Hopefully, he will respond in a much more intelligent fashion and be consistent. We will discuss the situation more in detail at followup sessions.
DIAGNOSES:
1. Adjustment disorder (309.9).
2. Oppositional defiant disorder (313.8).
PLAN: See the patient in 2-4 weeks.
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TIME OF APPOINTMENT: 8:30 to 9:15 a.m.
SUBJECTIVE: The patient is still uncomfortable and noncompliant with treatment. She is taking Risperdal, Zoloft and Aldoril. She never warmed up to be into this therapy session. We discussed the fact that it might be advantageous if she does not continue in treatment here but either seek treatment elsewhere or discontinue. The patient’s mother is somewhat frustrated but understanding the fact that nothing positive is going to come out of the situation, as she refuses to be compliant with treatment. Therefore, termination services will occur.
OBJECTIVE: The patient was calm and cooperative. Maintained fair eye contact. Speech was within normal limits. No evidence of psychosis. The patient’s mood is neutral, full range. Appropriate affect. The patient is alert and oriented x3. Attention and concentration fair. Insight and judgment fair. Memory appears to be intact.
ASSESSMENT: The patient just has not been interested in therapy. She is being forced to attend by her mother. As a result, no progress has significantly been made. The patient does not want to continue and it seems pointless to try to force her to do so, rather to allow her to have some independence, make this decision and perhaps seek treatment elsewhere or return at a later date. Mother finally agreed.
DIAGNOSES:
1. Adjustment disorder (309.9.
2. Attention deficit hyperactivity disorder (314.01).
PLAN: See the patient per her own scheduling.
