Case Management Progress Note PDF

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Case Study...

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Case Management Progress Note Directions: Complete the following progress note using the information from part I of the Case Study of Allison. Refer to the "Guidelines for Writing a Soap Note" resource to guide you through completing the progress note for Allison.

Client:

Allison Williams

ID#:

9262013

Date:

8/30/2020

S (Subjective): Allison presented at the agency today for her case management visit, she reports that “she is feeling overwhelmed. She states that nothing she does will make it better, and that she will never fall in love again. She states that nothing is enjoyable anymore, and the only way she can dull the feelings of pain and the emotions of worthlessness is to drink; but when she is intoxicated, she just feels worse”. O (Objective): Allison appeared to be wearing clothes that she slept in and her hair was unwashed, hanging in her face. She looked like she had been crying due to the bags under her eyes. A (Assessment): Allison sat quietly, staring at the floor, with her arms folded around herself, as if giving herself a hug. At times, it appeared as if she was rocking back and forth. When she arrived, Allison slowly walked back to the office, looking at the floor.

P (Plan): Ct. is to follow up on the referral for local group counseling twice a week, cognitive behavioral therapy once or twice a week for 30- to 60-minute sessions over 12 to 20 weeks, attend alcohol anonymous once a week for 1 hour for the next 9 weeks, and Dialectical Behavior Therapy (DBT) Individual treatment once a week for 1.5 hour for the next 9 weeks.

Cotia Wallace 8/30/2020 Case Manager Signature and Date

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