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Progress Note

Savanah, a 17-year-old cheerleader and student, began therapy at her mother's request due to concerns about her extreme desire to be healthy. Savanah reported feeling pressure to maintain a good image and stay thin but admitted symptoms like fainting and losing her period were not healthy. She stated she wanted help controlling her life rather than her condition controlling her. The therapist observed Savanah presented appropriately for their session. She was diagnosed with mild Anorexia Nervosa, Restricting Type. Treatment goals included increasing Savanah's BMI, improving communication with her mother, and enhancing her nutritional knowledge to support long-term health.

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Progress Note

Savanah, a 17-year-old cheerleader and student, began therapy at her mother's request due to concerns about her extreme desire to be healthy. Savanah reported feeling pressure to maintain a good image and stay thin but admitted symptoms like fainting and losing her period were not healthy. She stated she wanted help controlling her life rather than her condition controlling her. The therapist observed Savanah presented appropriately for their session. She was diagnosed with mild Anorexia Nervosa, Restricting Type. Treatment goals included increasing Savanah's BMI, improving communication with her mother, and enhancing her nutritional knowledge to support long-term health.

Uploaded by

api-317614978
Copyright
© © All Rights Reserved
Available Formats
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SOAP Progress Notes

Client: Savanah

Session #: 1

Date: 04/17/16

Therapist: Hannah M. Burleson


S Subjective: Completethesubjectivesectionofthenoteswithinformationthatthepatienthasrelateddirectlytoyou.Thissection
includesopinionbasedinformationfromthepatient:feelings,concerns,goalsfortherapy,etc.Includepertinentcommentsfrom
friends,family,caseworkersorotherpeopleclosetotheclient.

Today was Savanahs initial therapy session. She reported that she was there at the requirement of her mother,
who is concerned that her desire to be healthy is getting extreme. Savanah referenced a couple of events that
caused her mother to become concerned: 1) a couple of weeks ago, Savanah passed out while running, and 2)
Savanah has not had her normal period in four months. Savanah shared that she has lots of friends, is involved
in cheerleading, and is dating a star football player. She indicated that sometimes it is a lot of pressure to
maintain a good image and stay thin. Savanah stated, I dont think there is anything wrong with wanting to be
healthy. However, she admitted that feeling lightheaded, getting headaches, losing her period, and sometimes
passing out are not indicators of good health. Savanah stated, I want to get help and be in control of my life
rather than the other way around.
O Objective: Writeonlyfactbasedinformationintheobjectivesectionofthenotes.Thisinformationincludesquantitative,
verifiableevidence,suchaswhatcanbedirectlyobservedbythefivesensesandbyscientificmeasurements.Thiscanincludethe
clientsappearance,anymedicalmeasurementstakenandobviousbehavior.

Savanah, a 17-year-old Caucasian female, presented to the session on time and oriented times three. Mood,
affect, appearance, and personal hygiene were appropriate to the situation and session content. She was
expressive and open throughout the session.
A Assessment: Analyzetheclientsbehaviorandproblemsintheassessmentsectionofthenotes.ThissectionisusedforaDSM
diagnosis.

DSM 5Diagnosis:AnorexiaNervosa,307.1(F50.1),RestrictingType,Mild
P Plan: CreateaplanfortheclientstreatmentandrecorditinthissectionofyourSOAPnotes.Thissectioncancontainshort
termgoalsfromthemastertreatmentplanwithrecommendationsforfuturesessions.

ShortTermGoalsofTreatment:
Goal:(increase/decreasepersonalissue,behavior,orrelationaldynamic)to(increase/reducesymptom)
1.ClientwillincreaseBMItoreducesymptomsofAnorexiaNervosa.
Measure:ClientsBMIwillreachthenormalrangeunderthecarefuldirectionofacollaboratingteamof
professionals
TreatmentInterventions:NutritionalTherapy
2.Clientwillincreasecommunicationwithhermomtoreduceriskofmisunderstandingsaboutbeinghealthy
Measure:Clientwilldemonstrateabilitytocommunicateclearlyandeffectivelywithhermotherregarding
hermothersexpectationsaboutbeinghealthy.

SOAP Progress Notes


TreatmentInterventions:FamilyTherapy
3.Clientwillincreasenutritionalknowledgetoincreaseabilitytomaintaingoodhealthinthelongterm.
Measure:Clientwilldemonstrateasolideducationonnutrition/healthfuleating
TreatmentInterventions:NutritionalTherapy
Future Recommendations:
No revisions to the current treatment plan are necessary at this time.
Hannah M. Burleson
Therapist

04/17/16
Date

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