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Psychiatry Progress Note

Jamie Alvarez · 2026-10-23 · 99214

Signed

Author: Nora Vale

Reviewer: Theo Linden

Subjective / Interview

Fictional patient reports improved sleep consistency and ongoing stress around work transitions. Reviewed progress since the previous visit.

Objective / Mental Status

Engaged and cooperative during the sample encounter. Speech clear, thought process organized, orientation intact.

Assessment

Example care goals remain focused on coping skills and daily functioning. Progress is gradual; continue to monitor reported symptoms.

Plan / Follow-up

Continue weekly sessions. Practice paced breathing and a structured sleep routine; review questionnaire responses at the next appointment.

Risk Assessment

Sample assessment: no acute safety concerns reported. Protective factors and support contacts reviewed.

Diagnosis

F41.1 — Generalized anxiety disorder (fictional example)

Patient Responses

Client History Form · 2026-09-16

Completed

Work transitions and difficulty relaxing.

GAD-7 · 2026-10-23

8 · Mild

Needs Processing

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