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Psychiatry Progress Note
Jordan Reyes
· 2026-10-23 · 99214
Draft
Author:
Elena Marlow
Clinical Note
Revision History (1)
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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)
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