ROLON-TORRES v. KIJAKAZI, ACTING COMMISSIONER OF SOCIAL SECURITY

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA EVELYN ROLON-TORRES, : : Plaintiff, : CIVIL ACTION : v. : : KILOLO KIJAKAZI, : No. 22-cv-00223-RAL Acting Commissioner of Social Security, : Defendant : RICHARD A. LLORET February 27, 2023 U.S. Magistrate Judge MEMORANDUM OPINION The Commissioner of Social Security, through the decision of an Administrative Law Judge (“ALJ”), denied Evelyn Rolon-Torres’ (“Ms. Rolon-Torres” or “Plaintiff”) application for Social Security disability benefits. The Appeals Council affirmed the decision. This appeal followed. The ALJ determined that Ms. Rolon-Torres was not disabled under the Social Security Act’s (“SSA”) regulations. R. 17.1 Plaintiff requests review of the ALJ’s decision. Doc. No. 8 (“Pl. Br.”)2 at 1. Because I find that the ALJ erred, I remand the decision. PROCEDURAL HISTORY In 2020, Plaintiff filed an application for disability and disability insurance benefits (“DIB”). In her application, Plaintiff alleged a disability onset date of May 12, 2019, citing Herniated Disk, Sciatica, Anxiety, Depression, and Vertigo diagnosis. R. 186. In 2020, Ms. Rolon-Torres’ application was denied at the initial level of review. R. 1 All references to the administrative record are listed as “R. ___.” The administrative record is ECF Doc. No. 15. 2 Unless otherwise noted, as here, all references to the electronically docketed record are cited as “Doc. No. __ at __.” 218. In December 2020, Plaintiff requested a hearing before an ALJ. R. 101. The request was granted, and a hearing was held via teleconference in April 2021. R. 16. Ms. RolonTorres and Denise Cordes, a vocational expert, testified at the hearing. R. 16, 159-84. The ALJ found Ms. Rolon-Torres was not disabled. R. 16. After proceeding through the SSA’s appellate process, Ms. Rolon-Torres appealed in this court in 2021. Doc. No. 1. FACTUAL BACKGROUND A. The Claimant’s Background Ms. Rolon-Torres was 46 years old at the alleged disability onset date, making her a “younger person” under the regulations. R. 188; 20 C.F.R. §§ 404.1563 . From 1997-1998 and from 2002-2010, Ms. Rolon-Torres worked for Stasky Inc. as an executive maid. R. 215, 335. From 2016-2019, Plaintiff worked for Bravo Healthcare Services, Inc.3 as an environmental servicer/cleaner. R. 215, 334. B. The ALJ’s Decision The ALJ found that Ms. Rolon-Torres was not disabled under the SSA from May 12 through December 31, 2019. R. 17. In reaching this decision, the ALJ made the following findings of fact and conclusions of law pursuant to Social Security's five-step, sequential evaluation process.4 3 Bravo Healthcare Services, Inc. is also referred to as Bravo Group Services in the record. See e.g., R. 328. 4 An ALJ evaluates each case using a sequential process until a finding of “disabled” or “not disabled” is reached. The sequence requires an ALJ to assess whether the claimant: (1) is engaging in substantial gainful activity; (2) has a severe “medically determinable” physical or mental impairment or combination of impairments; (3) has an impairment or combination of impairments that meet or equal the criteria listed in the social security regulations and mandate a finding of disability; (4) has the RFC to perform the requirements of his past relevant work (“PRW”), if any; and (5) is able to perform any other work in the national economy, taking into consideration his RFC, age, education, and work experience. See 20 C.F.R. §§ 404.1520 (a)(4)(i)–(v), 416.920(a)(4)(i)–(v). First, the ALJ determined that Ms. Rolon-Torres was last insured on December 31, 2019, pursuant to the SSA’s insured status requirements. 5 R. 18 . At step one, the ALJ determined that Ms. Rolon-Torres had not engaged in any substantial gainful activity during the alleged disability period. Id. At step two, the ALJ held that Ms. Rolon-Torres had five severe impairments: Degenerative Joint Disease in the right knee, right hip bursitis, Degenerative Disc Disease of the lumbar spine, Major Depression, and General Anxiety Disorder. R. 18-19. The ALJ also determined that Ms. Rolon-Torres had moderate limitations in all four Paragraph B mental health limitations. 6 R. 21 -22. At step three, the ALJ compared Ms. Rolon-Torres’ impairments with those contained in the Social Security Listing of Impairments (“listing”).7 The ALJ found that Ms. RolonTorres’ impairments failed to meet any listing criteria or medically equate to a listing’s severity, individually or in combination. R. 19-22. Prior to step four, the ALJ determined that Ms. Rolon-Torres had the residual functional capacity (“RFC”) to perform light work that included occasional “stooping, crouching, crawling, and kneeling, as well as climbing ramps and stairs.” R. 22. The ALJ determined that Ms. Rolon-Torres was “limited to perform simple, routine tasks; make simple work-related decisions; and have frequent contact with the public, supervisors, 5 When an applicant is seeking disability insurance benefits (“DIB”) the ALJ must determine the applicant’s insured status. 20 C.F.R. § 404.101 (a). If an applicant is “neither fully nor currently insured, no benefits are payable based on [the applicant’s] earnings.” Id. The applicant is able to recover DIB only through their last insured period. 42 U.S.C. § 423 (a). 6 The four “Paragraph B” areas are (1) understand, remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself. Id. The ALJ determines if the complainant has a limitation in these four categories on a sliding scale, with the least limitation being “no limitation” and the most severe limitation as an “extreme” limitation. 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00F(2). 7 The regulations contain a series of “listings” that describe symptomology related to various impairments. See 20 C.F.R. Pt. 404, Subpt. P., App. 1. If a claimant's documented symptoms meet or equal one of the impairments, “the claimant is conclusively presumed to be disabled.” Bowen v. Yuckert, 482 U.S. 137, 141 (1987). If not, the sequential evaluation continues to step four, where the ALJ determines whether the impairments assessed at step two preclude the claimant from performing any relevant work the claimant may have performed in the past. Id. and co-workers. She is further limited to work involving only occasional changes in the work setting.” Id. The ALJ found that Ms. Rolon-Torres could not perform occasional balancing; should not climb ladders, ropes, or scaffolds; and should “never work at unprotected heights.” Id. At step four, the ALJ determined that Ms. Rolon-Torres was “capable of performing past relevant work as a Cleaner, Housekeeper,” leading to her determination that Ms. Rolon-Torres was not disabled under the SSA. R. 26. STANDARDS OF REVIEW My review of the ALJ’s decision is deferential. I am bound by her findings of fact to the extent those findings are supported by substantial evidence in the record. Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir. 2000) (citing Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999)). Accordingly, my review is limited to determining if substantial evidence supports the decision. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999) (citing 42 U.S.C. § 405 (g)). If the ALJ’s decision is supported by substantial evidence, her disability determination must be upheld. Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005); see also § 405(g). “A reviewing court reviews an agency’s reasoning to determine whether it is ‘arbitrary’ or ‘capricious,’ or, if bound up with a record-based factual conclusion, to determine whether it is supported by ‘substantial evidence.’” Dickinson v. Zurko, 527 U.S. 150, 164 (1999). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). Substantial evidence “is more than a mere scintilla but may be less than a preponderance.” Brown v. Bowen, 845 F.2d 1211, 1213 (3d Cir. 1988). I must rely on the record developed during the administrative proceedings along with the pleadings in making my determination. See § 405(g). I may not weigh the evidence or substitute my own conclusions for the ALJ’s. Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2011). I must defer to the ALJ’s evidentiary evaluation, witness assessment, and reconciliation of conflicting expert opinions. Diaz v. Comm’r of Soc. Sec., 577 F.3d 500, 506 (3d Cir. 2009). The ALJ’s legal conclusions and application of legal principles are subject to plenary review. See Krysztoforski v. Chater, 55 F.3d 857, 858 (3d Cir. 1995). I must determine whether the ALJ applied the proper legal standards in reaching the decision. See Coria v. Heckler, 750 F.2d 245, 247 (3d Cir. 1984). Accordingly, I can overturn an ALJ’s decision based on incorrect application of a legal standard even where I find the decision is supported by substantial evidence. Payton v. Barnhart, 416 F. Supp. 2d 385, 387 (E.D. Pa. 2006) (citing Friedberg v. Schweiker, 721 F.2d 445, 447 (3d Cir. 1983)). DISCUSSION Ms. Rolon-Torres argues for remand on four grounds. First, she claims the ALJ erred as a matter of law when finding that Ms. Rolon-Torres could perform her past relevant work (“PRW”), because the position was performed as a composite job and at a higher exertional level than the RFC limitations. Pl. Br. at 3-8. Second, the ALJ failed to account for Ms. Rolon-Torres’ moderate limitation in her ability to concentrate, persist, and maintain pace. Id. at 8-12. Third, the ALJ derived power in violation of the Constitution’s Separation of Powers clause.8 Id. at 12-15. Fourth, the ALJ and Appeals Council’s authority was improper, because the ALJ was illegally appointed under the Federal Vacancies Reform Act (FVRA), 5 U.S.C. § 3346 (a). Id. at 15-17 . I address only 8 In her reply brief, Ms. Rolon-Torres withdrew this argument. Doc. No. 10, at 11. As this ground for relief has been withdrawn, I will not address it here. ground one and two, and, based upon the discussion below, I find that this matter warrants remand. A. The ALJ Failed to Adequately Take into Account Ms. RolonTorres’ Moderate Limitation in Her Ability to Concentrate, Persist, and Maintain Pace at Step Four and Failed to Appropriately Explain Why the Limitation Was Omitted from the RFC. Plaintiff argues the ALJ committed reversable error when she omitted Ms. RolonTorres’ moderate limitation in the ability to concentrate, persist, and maintain pace in the residual functional capacity determination and resulting step four analysis. Pl. Br. at 8-12; Doc. No. 10 (“Pl. Reply Br.”) at 6. The Commissioner responds that the ALJ need not use specific language in her step four and five analyses, and the ALJ’s opinion properly expressed the limitation. Doc. No. 9 (“Def. Resp.”) at 25. The Commissioner is correct: specific language is not required to communicate limitations found at steps two and three. However, the ALJ failed to explain why Ms. Rolon-Torres’ moderate limitation in ability to concentrate, persist, or pace herself was not reflected in the RFC or the hypotheticals posed to the vocational expert. The step two analysis requires the ALJ to determine if the claimant has a medically determinable impairment that is severe or if there is a combination of impairments that are severe. 20 C.F.R. § 404.1520 (c). The ALJ determined that Ms. Rolon-Torres had moderate limitations in all four mental disorder “Paragraph B” criteria,9 including Ms. Rolon-Torres’ ability to concentrate, persist, or maintain pace. 9 The SSA defines “Paragraph B” criteria as “the functional criteria we assess, in conjunction with a rating scale (see 12.00E and 12.00F), to evaluate how [the claimant’s] mental disorder limits [their] functioning.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1, 12.00A(2)(b). The areas of mental functioning are (1) understand, remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself. Id. The ALJ determines if the complainant has a limitation in these four categories on a sliding scale, with the least limitation being “no limitation” and the most severe limitation as an “extreme” limitation. Id. at 12.00F(2). R. 21. A complainant’s ability to concentrate, persist, or maintain pace refers to “the abilities to relate to and work with supervisors, co-workers, and the public.”10 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00E(3). Here, the ALJ determined that Ms. Rolon-Torres had a moderate limitation in these interactions. R. 21. An ALJ finds a moderate limitation when the claimant’s “functioning in this area independently, appropriately, effectively, and on a sustained basis is fair.” 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00F(2)(c). Between steps three and four, the ALJ determines the claimant’s RFC.11 20 C.F.R. § 404.1520 (e). A claimant’s RFC is her ability to perform work activities’ physical and mental demands on a sustained basis. Id. The ALJ considers any and all limitations the individual has that are “functional limitations and restrictions that result from an individual’s medically determinable impairment or combination of impairments.” SSR 96-8p, *1; see 20 C.F.R. § 404.1520 (e). A person’s RFC is “not the least an individual can do despite his or her limitations or restrictions, but the most.” SSR 96-8p, *1. The ALJ found that Ms. Rolon-Torres had an RFC permitting light work. . . except occasional balancing. . .; occasionally stooping, crouching, crawling, and kneeling, as well as climbing ramps and stairs; however, no climbing of ladders, ropes, scaffolds. While the claimant can endure exposure to extreme cold, she can never work at unprotected heights. The claimant is limited to perform simple, routine tasks; make simple work-related decisions; and have frequent contact with the public, supervisors, and co-workers. She is further limited to work involving only occasional changes in the work setting. 20 C.F.R. § Pt. 404, Subpt. P, App. 1 10 The SSA provides a non-exhaustive list on what conduct the definition may include: “cooperating with others; asking for help when needed; handling conflicts with others; stating [one’s] own point of view; initiating or sustaining conversation; understanding and responding to social cues (physical, verbal, emotional); responding to requests, suggestions, criticism, correction, and challenges; and keeping social interactions free of excessive irritability, sensitivity, argumentativeness, or suspiciousness.” 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00E(3). 11 The RFC should be calculated prior to or at the beginning on step four, because “RFC is an issue only at steps 4 and 5 of the sequential evaluation process.” SSR 96-8p, *3. R.22. Plaintiff argues that this RFC “failed to include ANY word-related limitations to account for Ms. Rolon-Torres’s moderate limitation in concentrating, persisting, or maintaining pace.” R. 22. Pl. Br. at 10. At step four, the ALJ had to determine if claimant’s RFC allowed her to perform her PRW. 20 C.F.R. § 404.1520 (e). The ALJ had to first compare the RFC to the claimant’s PRW as actually performed. SSR 96-8p. If the complainant could no longer perform the PRW as actually performed, then the ALJ had to review if the complainant could perform the PRW as generally performed in the national economy. Id. The ALJ did this by asking the vocational expert hypothetical questions that incorporated the RFC limitations. R. 177-181. Ms. Rolon-Torres focuses on the interplay between the RFC and PRW, arguing that the “limitations that the ALJ finds credible at steps two and three cannot simply disappear at steps four or five, all limitations found credible by the ALJ must be incorporated into the RFC in some form.” Pl. Br. at 12 (citing Ramirez v. Barnhart, 372 F.3d 546 (3d Cir. 2004)). In Ramirez, the Third Circuit rejected a hypothetical containing a limit to “one to two step tasks,” finding it failed to “accurately convey” all the complainant’s impairments. 372 F.3d 546, 554 . An ALJ must accurately convey all impairments when presenting a hypothetical to a vocational expert. Id. at 552 . The hypothetical need not be a verbatim recitation of the RFC. Id. at n. 2. The Third Circuit found that the hypothetical’s “one to two step tasks” limitation failed to accurately convey that the claimant “often has deficiencies in concentration, persistence, or pace,” 12 because the 12 Ramirez was decided when the ALJ used a “never, seldom, often, frequent, and constant” limitation scale to define a limitation’s severity. 20 C.F.R. § 416 .920a (1999). Today, ALJs follow a “none, mild, moderate, marked, and extreme limitation” scale. 20 C.F.R. § 416 .920a(c)(4). “[T]he weight of authority suggests that the two scales are functionally equivalent.” Sawyer v. Berryhill, 305 F. Supp. 3d 664, 669 (E.D. Pa. 2018) (collating E.D. Pa. caselaw indicating that “often” is equivalent to “moderate”). language failed to convey a pacing limitation. Id. at 554 (internal citations omitted). An accurate hypothetical must communicate the employee’s limitations in maintaining the requisite output that employers expect in addition to limitations to performing no more than “one to two step tasks.” Id. The Third Circuit acknowledged that the ALJ may have had “a valid explanation for this omission” such as a determination “that the deficiency in pace was so minimal or negligible that, even though Ramirez ‘often’ suffered from this deficiency, it would not limit her ability to perform simple tasks under a production quota.” Id. at 555. Fourteen years later, Judge Beetlestone considered “whether the ALJ was obligated to include in his hypothetical the fact that Plaintiff has a ‘moderate’ limitation in his concentration, persistence, or pace.” Sawyer v. Berryhill, 305 F. Supp. 3d 664, 666 (E.D. Pa. 2018). In Sawyer’s hypothetical, the ALJ presented a limitation that Sawyer’s potential job required “no detailed instructions” and provided no specific language regarding a moderate limitation in concentration, persistence, or pace. Id. at 671 . The Court determined that the hypothetical was improper, as “[a] limitation to ‘no detailed instructions,’ says less about an individual's ability to concentrate, persist, or keep pace than the limitation in Ramirez because it only refers to an employee's ability to learn instructions, rather than perform.” Id. at 671 (citing to Ramirez, 372 F.3d 546 ). The court specifically rejected arguments that a hypothetical with “simple routine tasks” or “unskilled work” limitations could appropriately communicate a moderate limitation in concentration, persistence, or pace. Id. (declining to follow Menkes v. Astrue, 262 F. App'x 410 (3d Cir. 2008) and McDonald v. Astrue, 293 F. App'x 941 (3d Cir. 2008), both of which are non-precedential). As did Ramirez, Sawyer recognized that “the ALJ may have a valid explanation for limiting his hypothetical to those requiring only ‘no detailed instructions.’ . . . The ALJ, however, provided no such explanation for his omission.” Sawyer, 305 F. Supp. 3d at 671 . The court remanded the case, because it lacked the authority to “impute reasons why the ALJ did not include the limitation in his hypothetical or whether his failure to do so is harmless in this case.” Id. Hess, decided the following year, again considered whether an ALJ’s hypothetical properly communicated a claimant’s moderate limitation in concentration, persistence, or pace. Hess v. Comm'r Soc. Sec., 931 F.3d 198, 200 (3d Cir. 2019). The ALJ stated that Hess was “limited to jobs requiring understanding, remembering, and carrying out only simple instructions and making only simple work-related decisions.” Id. The district judge (Judge Beetlestone, as in Sawyer) concluded that the hypothetical failed to communicate the pacing limitation; the government appealed. Id. at 200-01 . Hess held that the ALJ was not restricted to particular language when conveying the limitation findings. The “social security regulations permit, and indeed require, an ALJ to offer ‘a narrative discussion describing how the evidence supports each’ limitation at step four of the disability analysis.” Id. at 209 (quoting SSR 96-8P, at *7). The Third Circuit clarified that the ALJ is not restricted to the functional limitation language at later steps of her analysis, but the findings are relevant and the language of the functional limitation must sufficiently reflect the found impairments. Id. at 210 . The Third Circuit held that an ALJ may use a “simple task”13 in a hypothetical to convey a moderate limitation in concentration, persistence, or pace, so long as the ALJ 13 A “simple task” equates “to jobs requiring understanding, remembering, and carrying out only simple instructions and making only simple work-related decisions.” Id. at 210-11 (internal citations omitted) (compiling cases and social security regulations). provides a “valid explanation.” Id. at 211 (citing Ramirez, 372 F.3d at 554-55 ). “Without explanation, such a limitation does not warrant a conclusion about whether a claimant’s difficulties in ‘concentration, persistence, or pace’ are so serious that he cannot satisfy the functional requirements of ‘simple tasks.’” Id. at 213. This standard is a fact specific standard that must be determined on a case-by-case basis. Id. at 212. The Court implemented the standard and found that the ALJ used “sound reasoning” to determine that the moderate limitation was not severe enough to impede Hess’ ability to perform simple tasks. Id. at 213-15. The ALJ explained “that Hess’s ‘selfreported activities of daily living, such as doing laundry, taking care of his personal needs, shopping, working, and paying bills (when he has money), . . . are consistent with an individual who is able to perform simple, routine tasks.’” Id. at 213–14 (internal citations omitted). The ALJ also appropriately reasoned “that ‘progress notes from treating and examining sources” were persuasive, because these sources indicated “no serious problems in this area of functioning, reporting that [Hess] could perform simple calculations, was fully oriented, and had intact remote/recent memory.’” Id. (internal quotations and citations omitted). The basic criticism of the “simple tasks” limitation, in Ramirez and Hess, is that saying a task is “simple” and that a claimant can understand it and do it says nothing much about how the claimant will perform in a work setting that requires her to do the task with concentration, persistence, and pace. Both Ramirez and Hess offer a fix for this problem: a “valid explanation.” As Ramirez puts it, a “valid explanation” is one that makes it clear “that the deficiency in pace was so minimal or negligible that, even though Ramirez ‘often’ suffered from this deficiency, it would not limit her ability to perform simple tasks under a production quota.” Ramirez, 372 F.3d at 555 . It is possible to provide the requisite explanation in one simple declarative sentence, as suggested in Ramirez. The problem in Hess was that the one sentence suggested in Ramirez went missing. Hess did not overrule Ramirez, it applied it. Reading the two cases together, it is clear that a limitation in the RFC to “simple tasks” is not a mantra that suffices, without more, to take into account a claimant’s moderate limitations in concentration, persistence, and pace. Ramirez makes that plain, contra language in Menkes, a nonprecedential case (“For example, performing a ‘simple routine task’ typically involves low stress level work that does not require maintaining sustained concentration.” 262 F. App'x 410, 412 .). Hess made it clear that an ALJ may account for a claimant’s limitations in concentration, persistence, and pace by a “simple tasks” limitation in the RFC when the ALJ provides a “valid explanation” of his or her reasoning. Ramirez described what this explanation would look like. 372 F.3d at 555 . Hess considered the ALJ’s explanation in that case in detail and decided that it sufficed. The question is whether the ALJ in Ms. Rolon-Torres’ case supplied a “valid explanation,” as in Hess, or failed to provide such an explanation, as in Ramirez. To reiterate, Ms. Rolon-Torres’ RFC permits light work restricted to “simple, routine tasks;” “simple work-related decisions;” and “frequent contact with the public, supervisors, and co-workers.”14 R. 22, 24. The ALJ limited Ms. Rolon-Torres “to work involving only occasional changes in the work setting.” Id. The RFC, by its explicit language, fails to account for Ms. Rolon-Torres’ limitations in concentration, persistence, and pace. The question, then, is whether the ALJ adequately explained, as 14 I omit the ALJ’s physical limitations because this analysis pertains only to mental limitations. in Hess, why a limitation to simple tasks, without more, sufficed to account for Ms. Rolon-Torres’ moderate limitations in concentration, persistence, and pace. I turn to the ALJ’s explanations. The ALJ determined that Ms. Rolon-Torres addressed her mental impairments with “routine and conservative” treatment, “without frequent emergency department visits, crisis interventions, or psychiatric hospitalizations during the relevant period.” R. 25. This amounts to a generalized commentary on Plaintiff’s mental health, and does not grapple with the issue identified in Ramirez and Hess. Even if it did, the conclusion that Ms. Rolon-Torres received “conservative” treatment regarding her mental health, and the inferential light this casts on the functional limitations imposed by her condition, is not supported by opinion evidence, at least none cited by the ALJ. It can be appropriate for a doctor to form an opinion that one would expect to see a more aggressive treatment history for a mental condition if it represented a serious functional limitation. Such an opinion would be based upon the doctor's years of medical training and clinical experience, and it would enable him or her to come to some general rule-of-thumb about the relationship between an aggressive treatment history and the severity of the disorder. Such an opinion is often offered by an examining or consulting physician and can form the basis of an ALJ's determination that the level of treatment is not commensurate with the limitations claimed by the applicant or the treating physician. The record contained such analysis regarding Ms. Rolon-Torres’ physical ailments, but not her mental ailments. See R. 618-19 (medical notes outline that Ms. Rolon-Torres’ pain was not responding to conservative therapy). Absent medical opinion evidence, there is no basis to make a valid inference that conservative treatment meant a condition of no functional consequence. It could just as easily be the case that “aggressive” treatment offered no better hope of improvement. The ALJ found the opinions of State agency physician Marci Cloutier, Ph.D. (“Cloutier”) and State agency psychologist Anthony A. Galdieri, Ph.D. (“Galdieri”)15 partially persuasive, because the opinions “did not assess restrictions [in] interacting with others.” R. 26. The ALJ relied on Dr. Cloutier to find that Plaintiff “could understand, retain, and follow simple instructions (e.g., perform one-and-two-step tasks), make simple decisions, and would not require special supervision in order to sustain a routine, despite her impairments.” R. 25; and see R. 192-94. The ALJ further found, based on Dr. Cloutier’s opinion, that Ms. Rolon-Torres was “able to meet the basic mental demands of work on a sustained basis.” R. 26. Id. The ALJ found that though Dr. Cloutier did not assess restrictions interacting with others, such limitations were appropriate, given Mr. Rolon-Torres’ symptoms of depression and anxiety. R. 26. None of this addresses the issue identified in Hess and Ramirez. Hess provides a working example of a “valid explanation” that sufficed even without a straightforward sentence of the kind suggested in Ramirez. In Hess, the ALJ “coupled” her finding about the claimant’s moderate limitations with an explanation that the claimant’s activities of daily living were consistent with someone able to do simple routine tasks. 931 F.3d at 214 . In the same discussion, the ALJ said progress notes from treating and examining sources indicated “no serious problems in this area of functioning.” Id. At another point in the ALJ’s discussion, the ALJ mentioned that the claimant’s activities of daily living demonstrated Hess could work as a dishwasher, and 15 Galdieri concurred with Cloutier. R. 198-206. there were no reports of problems completing tasks during a period of close observation. Id. Comparing this case to Hess is instructive. Here there is no “coupling” of a discussion of the claimant’s activities of daily living with the capacity to do simple tasks. There is no language about progress notes that reflect “no serious problems in this area of functioning,” as in Hess. Id. at 214 . Quite the contrary, a survey of the treatment notes reveals Ms. Rolon-Torres had serious mental illness problems for years. See Resp. at 26, with record citations. There is no mention by the ALJ of the observed ability to complete work tasks without problems, as in Hess. 931 F.3d at 214 . Of course, Hess is an example of how a “valid explanation” might look, not an exclusive template. Hess emphasizes that an ALJ need not “chant every magic word correctly” to avoid being remanded. 931 F.3d at 198 . Nevertheless, the ALJ’s opinion in this case provides neither Ramirez’s “one sentence” explanation nor the level of detailed, albeit tangential, explanation furnished by the ALJ in Hess. The Commissioner points to the ALJ’s citation of “various medical records” and explanation that “mental status examinations documented both positive and negative findings, and that such findings supported her RFC assessment.” Resp. at 27 (citing the ALJ’s opinion at R. 24, 26; which in turn cites to many pages within the record). This amounts to a generalized commentary on Plaintiff’s mental health, but does not address the issue identified in Ramirez and Hess. I have reviewed in detail the record cites by the ALJ and the Commissioner and they paint a sad and unremitting picture of a severely depressed and anxious woman with much to be depressed and anxious about, including the suicide of her son, the incarceration of her husband, constant pain, and financial stress. Nothing in the cited portions of the record addresses the issue identified in Ramirez and Hess. The ALJ and the Commissioner note that “Plaintiff’s symptoms improved with therapy and psychiatric mediations.” Resp. at R. 21-22, 24 (citing to medical records). No, they didn’t. I carefully examined the medical records cited at page 27 of the Commissioner’s response, and at R. 24 (the ALJ’s opinion). I prepared and attached an appendix of actual language taken from both the record pages cited by the ALJ and pages in between. To say that the record supports the conclusion that Ms. Rolon-Torres’ symptoms “improved” with treatment is simply incorrect. The best that can be said is that on a handful of occasions during treatment that lasted three years the word “better” or “improved” was used to describe how Ms. Rolon-Torres felt, compared to her last visit.16 The record clearly undercuts the ALJ’s characterization of Ms. Rolon-Torres as “improved” with treatment. Compare, e.g., Appendix, p. 42 (March, 2021) with p. 2 (February/March, 2018). The conclusion that Plaintiff “improved” with treatment is not supported by substantial evidence. Where the line between sufficient and insufficient explanation should be drawn, given Ramirez and Hess, is much debated in the cases, but a line must be drawn. I am not free to ignore the teachings of either Ramirez or Hess; both are precedential. In this instance I find the ALJ did not provide a “valid explanation,” under either Ramirez or Hess, of how a “simple tasks” limitation in the RFC sufficed to address Ms. RolonTorres’ moderate limitations in concentration, persistence, and pace. The explanation 16 This was “cherry-picking.” “‘Cherry-picking’ is a term used to describe selective citation of the record to support an opinion that is not supported by a fair and complete review of the entire record. See Smith v. Berryhill, No. 17-2661, 2018 WL 7048069 , at *9 (E.D. Pa. Nov. 27, 2018) (Hey, MJ) (collecting cases).” Cordero v. Kijakazi, 597 F.Supp.3d 776 , 816–17 n.51 (E.D. Pa. 2022) was not “valid” because it was based on flawed inferences and a misreading of the record. This mattered: the vocational expert testified in response to an alternative hypothetical that a functional limitation that allowed for moderate difficulties in persistence, concentration, and pace would result in no available jobs for Ms. RolonTorres. R. 180-81. Because the RFC was defective, the hypothetical upon which the vocational expert relied was also defective, meaning that the VE’s testimony in response to the hypothetical did not count as substantial evidence in support of the ALJ’s decision. Remand is appropriate. B. The ALJ Did Not Err When She Did Not Analyze If Ms. RolonTorres’ PRW Was a Composite Job. Plaintiff also asserts that the RFC determination was erroneous as a matter of law. Pl. Br. at 3. The ALJ found that Plaintiff could return to her PRW as a Cleaner, Housekeeper (DOT § 323.687-014) as generally performed. I find that the ALJ was correct and substantial evidence supports the decision. At step four, the ALJ must compare the complainant’s RFC to any PRWs. Reed v. Berryhill, 337 F.Supp.3d 525, 529 (E.D. Pa. 2018) (Rufe, J.) (internal citations omitted); SSR 82-61, 1982 WL 31387 . An ALJ determines an applicant’s PRW by reviewing “work done in the past 15 years, that was substantial gainful activity, and that lasted long enough for [the applicant] to learn it.” 20 C.F.R. § 404.1560 (b)(1); SSR 82-61, 1982 WL 31387 , at *1. Here, the ALJ determined that Ms. Rolon-Torres’ has PRW experience as a “Housekeeper (Cleaner, Housekeeping) . . ., which is a light exertion occupation (as generally performed) but at heavy exertion as actually performed.”17 R. 26. In making 17 The ALJ also determined that Ms. Rolon-Torres has PRW experience as a “Cleaner, Hospital (sample DOT code 323.687-010), which is a medium exertion job as generally and actually performed.” R. 26. Plaintiff does not make any assertion regarding this position. See Pl. Br. at 5-8. The ALJ does not comment on if Ms. Rolon-Torres can or cannot perform this job. R. 26. I will not review this PRW. the determination, the ALJ relied on Ms. Rolon-Torres’ testimony regarding her job duties and the vocational expert’s responses to the hypotheticals. R. 26. Once the ALJ decides if the applicant has a PRW, the ALJ then reviews if the applicant has an RFC to perform either “(1) [t]he actual functional demands and job duties of a particular past relevant job; or (2) [t]he functional demands and job duties of the occupation as generally required by employers throughout the national economy.” SSR 82-61, 1982 WL 31387 , at *1 (citing to 20 C.F.R. §§ 404.1520 (e), 416.920(e)). If the applicant can perform under either prong, the ALJ cannot find the applicant disabled. Id. Here, the ALJ relied on the vocational expert’s testimony to determine that Ms. Rolon-Torres “could perform the job of Cleaner, Housekeeper as generally performed.” R. 26, 180-81. The Plaintiff’s argument focuses on this two-part analysis. Plaintiff’s argument18 is that the ALJ erred because Ms. Rolon-Torres’ PRW was a composite job, which barred the general performance analysis of what employers in the national economy expect. Pl. Br. at 3. The Commissioner responds that the record does not contain any evidence indicating two or more jobs and the vocational expert’s testimony presents only one DOT position: Cleaner, Housekeeper. Com. Resp. 22-24. Plaintiff responds that the ALJ is the SSA’s rules and policy expert —not the vocational expert—and her determination was wrong. Pl. Reply Br. at 2. A composite job occurs when the individual’s PRW consists of “significant elements of two or more occupations and . . . have no counterpart in the DOT.” Past 18 In her first argument, Plaintiff argues the ALJ is precluded from finding that Plaintiff could perform her PRW as actually performed, because the vocational expert testified that Ms. Rolon-Torres actually performed at a heavy level of exertion. Pl. Br. at 4. The Commissioner posits this argument is moot, because the ALJ determined that Ms. Rolon-Torres could perform her PRW as generally performed. See Com. Resp. at 22-24. The ALJ indeed determined that Ms. Rolon-Torres could perform her PRW as generally performed, but not as actually performed. R. 26. This argument agrees with the ALJ’s determination, and is moot. Relevant Work (PRW) as the Claimant Performed It, SSA POMS DI 25005.020.19 “In other words, a composite position must involve additional main duties from another DOT position, rather than merely excessive functions with the job duties from one DOT position.” Reed, 337 F.Supp.3d at 529 (internal citation omitted); Giddings v. Berryhill, 2018 WL 4252426 , at *4 (E.D. Pa. Sept. 5, 2018) (Jones, J.). If the ALJ determines that the claimant’s PRW is a composite job, the ALJ must explain why. SSA POMS DI 25005.020. Once a composite job has been identified, the ALJ determines if the complainant can perform the job as actually performed. SSA POMS DI 25005.020. Since a composite job lacks a DOT definition, the ALJ cannot review if the complainant could perform the work as generally performed in the national economy. Id. In Reed, Plaintiff argued he previously performed a composite job, because his PRW included “additional functions beyond the DOT description of substance abuse counselor.” Reed, 337 F.Supp.3d at 529 . The Court denied the argument, because Reed, who held the burden to demonstrate he could not return to his prior job, failed to show that his PRW “included significant variations with the main duties included in another DOT position.” Id. (emphasis added). Weidner and Colon Martinez relied on Reed to affirm their holdings that the Plaintiff did not have a composite job. In Weidner v. Kijakazi, Plaintiff argued that her prior work experience was a composite job. 2022 WL 610702 , *7 (D. Del. Feb. 1, 2022) (slip copy). Weidner had two PRWs. The first was a receptionist position, which Weidner argued also entailed security duties and an emergency provision to provide personal care to residents. Id. at *8 . The 19 These POMS provisions are binding on all ALJs. SSR 13-2p, 2013 WL 621536 , *15. However, “[c]iting POMS provisions does not aid plaintiff. . . because they lack the force of law and create no judiciallyenforceable rights.” Colon Martinez v. Comm'r of Soc. Sec., 2019 WL 3336336 , at *4 (D.N.J. July 25, 2019) (internal quotations omitted) (citing to Bordes v. Comm'r of Soc. Sec., 235 F. App'x 853, 859 (3d Cir. 2007); Edelman v. Comm'r of Soc. Sec., 83 F.3d 68 , 71 n.2 (3d Cir. 1996)). Court found these extra duties were insufficient to classify the receptionist experience as a composite job, because testimony indicated that the extra performance occurred only two to three times per week and took about 15-30 minutes. Id. The Court rejected that her providing care duty was a sufficient additional duty, because there was no expectation to lift or physically assist residents. Id. Weidner’s second PRW was accounts payable, where Plaintiff asserted an additional duty to lift and carry heavy boxes upstairs to file. Id. The Court determined this PRW was not a composite job, because she was expected to lift and move heavy boxes about once every two days, which was far less than that of a file clerk, the alternative DOT position Plaintiff proposed. Id. at *9. The Plaintiff in Colon Martinez asserted that his gambling cashier PRW included significant elements of the change person DOT position. Colon Martinez v. Comm'r of Soc. Sec., 2019 WL 3336336 , at * 3 (D.N.J. July 25, 2019). The Court rejected the argument on five grounds: (1) the ALJ’s reliance on Plaintiff’s disability report and hearing testimony was appropriate when determining Plaintiff’s DOT position; (2) the ALJ appropriately relied on the vocational expert’s testimony that Plaintiff worked only as a gambling cashier; (3) Plaintiff failed to show that the job included significant elements of the change person’s job; (4) Plaintiff lifting coin bags was not a substantial job requirement; and (5) citing to POMS provisions is unpersuasive “because they lack the force of law and create no judicially-enforceable rights.” Id. at *3-4 (internal quotations omitted) (citing to Bordes v. Comm'r of Soc. Sec., 235 F. App'x 853, 859 (3d Cir. 2007); Edelman v. Comm'r of Soc. Sec., 83 F.3d 68 , 71 n.2 (3d Cir. 1996)). In this matter, Plaintiff argues that her Cleaner, Housekeeper PRW was a composite job. Pl. Br. at 6-8. The DOT defines Cleaner, Housekeeper as a position that can take place in “any industry,” and requires the employee to Cleans rooms and halls in commercial establishments, such as hotels, restaurants, clubs, beauty parlors, and dormitories, performing any combination of following duties: Sorts, counts, folds, marks, or carries linens. Makes beds. Replenishes supplies, such as drinking glasses and writing supplies. Checks wraps and renders personal assistance to patrons. Moves furniture, hangs drapes, and rolls carpets. Performs other duties as described under CLEANER (any industry) I Master Title. Definition of Cleaner, Housekeeper DOT § 323.687-014, 1991 WL 672783 . The Master title is defined as a light work position that can take place in any industry. CLEANER (any industry) I Master Title, 1991 WL 645969 . The position has the typical classifications of “Cleaner, Commercial or Institutional (any industry); Cleaner, Hospital (medical ser.); Cleaner, Housekeeping (any industry); Cleaner, Industrial (any industry); Housecleaner (hotel & rest.).” Id. The job-holder: [m]aintains premises of commercial, institutional, or industrial establishments, office buildings, hotels and motels, apartment houses, retirement homes, nursing homes, hospitals, schools, or similar establishments in clean and orderly condition, performing the following duties: Cleans rooms, hallways, lobbies, lounges, rest rooms, corridors, elevators, stairways, and locker rooms and other work areas. Sweeps, scrubs, waxes, and polishes floors, using brooms and mops and powered scrubbing and waxing machines. Cleans rugs, carpets, upholstered furniture, and draperies, using vacuum cleaner. Dusts furniture and equipment. Polishes metalwork, such as fixtures and fittings. Washes walls, ceiling, and woodwork. Washes windows, door panels, and sills. Empties wastebaskets, and empties and cleans ashtrays. Transports trash and waste to disposal area. Replenishes bathroom supplies. Replaces light bulbs. Classifications are made according to type of establishment in which work is performed. Id. The ALJ had no reason to consider if Plaintiff’s position was a composite job. First, the additional duties Plaintiff proposes are insignificant. To be a composite job, Ms. Rolon-Torres must have performed significant additional duties from another DOT profession. Plaintiff proposed additional duties: the job was performed in a residential setting, she moved items above the DOT’s light work classification, and she cleaned items not listed in the DOT’s definition. Pl. Br. 6-8. The vocational expert’s testimony indicates that the Cleaner, Housekeeper profession is routinely performed in a residential setting: Q: [A]nd the DOT code that you gave for the housekeeping/cleaner, is it correct that according to the Dictionary of Occupational Titles, by its very description, that covers people who work at places like hotels, restaurants, clubs, beauty parlors, dormitories? A: Correct. Q: Okay. And that does not indicate in there anything about cleaning residential settings, correct? A: When you look at employment by industry, in terms of this job, I mean, they’re giving me examples, okay, but they’re not telling you all places that a person can be involved in housekeeping/cleaning. In fact, the largest number of people working in this capacity, the largest—no, I shouldn’t say the largest, no—the largest number of people working in this capacity in the United States work in private households. Q: Okay. A: The second largest number is self-employed people. So, even though you’ve got, you’ve specified industries, that it’s not limited to that. R. 180-81. Working above the DOT’s defined exertion level is not an additional, substantial work duty. See Garcia v. Astrue, 2009 WL 1165342 , at *1 (E.D. Pa. Apr. 28, 2009) (upholding that Garcia’s PRW was not a composite job even though he was required “to regularly lift heavy drums, and heavy lifting is not included in the DOT definition”). None of these additional duties were significant additional duties performed in addition to the DOT’s defined main duties. Just performing the job duties in a residential setting rather than a commercial setting adds nothing significant to the job’s duties, at least not based on the evidence introduced in this case. Second, Ms. Rolon-Torres failed to establish the other DOT position with which her job performance aligns. Here, Ms. Rolon-Torres argues she did more than what was expected. Pl. Br. at 6. She failed to propose alternative DOT positions that supply the composite job duties both during the ALJ’s proceedings and before me. See Weidner, 2022 WL 610702 , at *8-9 (where Plaintiff proposed an alternative DOT position); Colon Martinez, 2019 WL 3336336 at *3 (same); and Giddings, 2018 WL 4252426 , at *4 (Plaintiff’s counsel asked the vocational expert about alternative DOT job descriptions). Plaintiff has not submitted an alternative DOT position or established supplemental duties as required for a composite job holding. I find the ALJ did not err in finding that Ms. Rolon-Torres could perform the DOT definition of Cleaner, Housekeeper as generally performed. CONCLUSION For the reasons explained above, Ms. Rolon-Torres’ request for review is granted, the final decision of the Commissioner is reversed, and this matter is remanded to the Commissioner for further proceedings consistent with this opinion. BY THE COURT: s/Richard A. Lloret RICHARD A. LLORET U.S. Magistrate Judge Appendix Contained in this appendix are snippets of all the Comprehensive Biopsychosocial Evaluations (“CBE”), Progress Treatment Notes, Psychological Treatment Notes, and Treatment Plan Updates that Cognitive Behavior Health Services Produced from February 5, 2018 to March 25, 2021 while treating Ms. Rolon-Torres. The excerpts are derived from Exhibits 4F (R. 554-602) and 12F (R. 841-1095), and are focused on Ms. Rolon-Torres’ self-reported mental health and treatment provider’s analysis of the therapy sessions each Progress Treatment Note summarizes. However, I have reordered the screenshots to proceed chronologically, so Ms. Rolon-Torres’ mental health is more accurately communicated. CBE Dated February 5, 2018. R. 554. Chief Complaint/Presenting Problem; Evelyn ABC's: A-Since my son died, every day I feel sad as if my being was broker into pieces. I warry that I can never overcome this. I have sought help but it is always the same. This month is the anniversary of the death of my son and that makes me feel even sadder B- "I don't know what happen to me, I'll never be happy again, that's terrible. dally easily irritable, nervous almost part of the day, crying for no reason hwo or three dimes a day, I’m not sleeping well just two or three firs per day , [ don"t want fo go nowhere, just the necessary". History of Present Illness: Evelyn start to feel depress in 2010 when her mother passed away she gat a lat af medical illness she was close io her. A year later in 2011 her oldest son committed suicide, he shoot himself, he had a litter baby boy, that was terrible for the family, six months later her husband, the father of her kids was incarcerated and she has been to do everything by herself was in treatment in Nueva Vida Behavioral health center for afew years and had been feeling better but had to stop the treatment because didn't have health insurance, This month is the anniversary of the death af my son and that makes me feel even sadder CBE Dated March 9, 2018. R. 561. Coon getting depressed again.” HPI: Hispanic fecnalewhtag.been on ambien-and Prozac, which'stie says marie her teal much better; none x1 year. 1 ubene cain: . "état knead . from there.” Context is that. son (20) wasSh7 years ago, "I didn’t know how to cope... how-to movecan irom the The year earlier, had also lost her mother; ayd.the same year asson’s:SA, the husband Hs jailed Than rrianaged to get better, until past Z.months has felt more depressed due.to her medical conditions: increasing BP vs hypaterision, also-vertigo (no meds—pending work up with ENT).. Says.the dizziness 1s bad, and causes her te stay home, decteaséd motivation and energy. ‘Also considerable LBP from sciatica, no-trauma, mo ares, Currently. working a parttimie.ds cleaning rooms-at CHOP, parttimic.. ssi. Says she “can boldonto-tt, it keensimy mindoccupied® but finds it hard to work sometimes. Poorsleep, latency. Appetite down, fast 25lbs ind.mos. Woody, low, often feels. apathetic. “dragging, not really want to da'things.” hopelessness. somatic x, flusiting, dizziness. Somewhat pessiniistic. At times.cries when thinking about son, psychosis, no thought disorder. -manla/ocd Progress Note Dated May 24, 2019. R. 1000-01. Chief comptaint: Evelyn looks bad, sick, referred that she came this day because her brother drive it here, and sold, Jam having too much pain in my right leg.“ MOOD CHECKING 5 _ (0-10). DIARY CARD OR COPING CARD? Yes__ No _X BRIDGING: About the reasons that | was not coming and all the things that I went through ” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): SUICIDAL BEHAVIOR? Yes__ No_X_ THERAPY INTERFERING BEHAVIOR? No_X SKILLS? Yes__ No_X AGENDA: I would like to talk how I will be dealing with this situation because now I am very negative “ MMAR RR cea geo ABC OR CHAIN ANALYSIS (VIF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WILAT TIME, CONSEQUENCES: IMMEDIATE, DELAYED):. A- “lam doing better but my health is not well, if continue with this pain I need to go to the emergency room B-“T think this will be a failure, I think that I am going crazy, | think that I have something bad and the doctors doesn't want to iell me nothing” . C- "I'm feeling very anxious two or three times a day every day , very depress and crying for no reason two or three times a day ” ‘Assess ‘semment ea ‘i □□ atk pee nate cae tee eae Ea ae eee Spaeuciacn om a DIAGNOSIS: (296.2F! 33.1) Major depressive Disorder, Recurrent episodes Interventhon: During the session, the therapist was actively listenin War encouraged to increase thase negative thoughts for a positive once, was talking ahout her health problems but is not anvihing That bad, was explained how we will go to be working fo contro! her ponies, Responsefeedback . Evelyn was very attentive and was quiet and relaxes. Progress Note Dated May 26, 2019. R. 1002-03. Chief complaint: Evelyn is comming fo reopen fer caxe affer almost 10 anwathy ana she said“ J was not coming because I dint howe fect ireerance fet now | have ary insurcnce buck, J been very sick with a tot of lower back ceried Unit sitwartion makes me feel so hed and frustrate , the fast year f hod two or three panics attack fresnel tea gevr fa thie deeaspaiten! feo ia” MOOD CHECKING__$___ (0-10). DIARY CARD OR COPING CARD? Yes__ No_X BRIDGING: | don't remember, | been in a lot of stress“ REVIEW OF HOMEWORK (WHAT DID YOU LEARN): Is a roopen, SUICIDAL BEHAVIOR? Yes__ No_X_ THERAPY INTERFERING BEHAVIOR? Yes __No X SKILLS? Yes__ No_X AGENDA: Complete the release form and treatment plan “ Objective eat Qaer ABC OR CHAIN ANALYSES (VF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME. CONSEQUENCES: IMMEDIATE, DELAYED). A- “Tam doing better but my health is not well, the last year I had a lot of panics attacks I am scare to have it again and be in the hospital” B-"] think this will be a failure, 1 think that I am going crazy. . C- "I'm feeling very anxious two or three times a day every day , very depress and crying Jor no reason two or three times a day “ Assessment tie oda at tana sep haar DIAGNOSES: (296.2F! 33.1) Major depressive Disorder, Recurrent episodes latervention: During ihe sewing, Me therapie wee actively livtwaing, way encouraged ly increuse ihove negative eres for postive ance, wus talking chau! ber beat problems bud is mod anyihing Perel, wees uypnlinianead Prova we well shee ted he wartking fe connect ber pamies. Response/feedback . Bebra wes eee ettomtiee one! wow quiet ane! redones, Progress Note Dated May 30, 2019. R. 998-99. Chief complaint: Evelyn looks bad. sick, said thot ix feeling a litter bir betier but continue out af work because the petin is eo aad” MOOD CHECKING __$ __ (0-10). DIARY CARD OR COPING CARD? Yes__ No_X BRIDGING: About my health situation” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL BEHAVIOR? Yes__No_X_ THERAPY INTERFERING BEHAVIOR? Yes ___No_X SKILLS? Yes__No_X AGENDA: 1 would like to talk how I will be dealing with this situation because now | am very negative “ ABC OR CHAIN ANALYSIS (VF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME, CONSEQUENCES: IMMEDIATE, DELAYED): A- “Iam doing better but my health is not well, the doctor said it is the same thing, a pinch nerve “ B-"I think this will be so bad if I continue like that because | will lose the job.” C- "I'm feeling very anxious two or three times a day every day , very depress and crying Sor no reason two or three times a day. DIAGNOSIS: (206.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention: During the session, the therapist was actively listening. was encouraged fo increase those negative thoughts for a positive once, was Jalking aboot her health problems And is net anveliag That bad, was explained how we will go to be working to control her panics. Responseffeedback: Evel wee very attentive and was quiet and relaxes, Progress Note Dated June 14, 2019. R. 996-70. Chief complaint: Evelyn looks sad, referred that she has been so bad, now J am coming fram the doctor and he said the hernia is bigger and that’s why she's having a lot of pain , but said, “I am warry because fam not working and J have everything back, my bills are late all my bills “ MOOD CHECKING___5__ (0-10). DIARY CARD OR COPING CARD? Yes_No_X BRIDGING: About my health situation” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL REHAVIOR? Yeo__ No_X_ THERAPY INTERFERING BEHAVIOR? Yes __No_X SKILLS? Yes_ No_X AGENDA: 1 would like to talk how I will be dealing with this situation because now | am very negative “ ABC OR CHAIN ANALYSIS (VF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS, PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME. CONSEQUENCES: IMMEDIATE, DELAYED):. A- “J. am not well, my health is not well, the doctor said that I have a hernia disk and not it is bigger , first they will try injection if not work I will need surgery “ B-“] think this will be so bad if I continue like that 1] will need a surgery but will be worst.” C- "i'm feeling very anxious two or three times a day every day , very depress and crying for no reason two or three times a day. " _ _ DIAGNOSIS: (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention: During the session, the therapist was actively listening, was encouraged te increave those negative thoughts for a positive once, we started to work with her problem solving first af all she need to call to wnemployment because she could apply and they could help her with the 40 ar 60% of her salary , another thing we gave her some telephone number of diferent programs which they help te pay the bills Response/feedback: Evelyn was very attentive and war quiet and relaxes, Progress Note Dated July 5, 2019. R. 994-95. Chief complaint: Evelyn looks sad. referred the she is having a better health ar the pain still there / can't even sleep” “MOOD CHECKING _§ (0-10), DIARY CARD OR COPING CARD? Yes__No_X BRIDGING: About my health situation” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL BEHAVIOR? Yes_ No_X_ THERAPY INTERFERING BEHAVIOR? Yes ___No_X SKILLS? Yes__No_X AGENDA: would like to talk how I will be dealing with this situation because now I am very negative “ ADC OR CHAIN ANALYSIS (VF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS, PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME, CONSEQUENCES: IMMEDIATE, DELAYED): A- “Lam not well, my health is not well, I had a cortisone injection but the pain still there. " think this will be so bad if I continue like that Iwill need a surgery but will be worst.” C- “I'm feeling very anxious two or three times a day every day , very depress and crying for no reason hwo or three times a day.” □□□□□□□□□□□□□□□□□□□□□□□□ bang omecapeamsscer tpawremene ne SRNR SSIES cece a ean ea ee ee eg DIAGNOSIS: (26.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention: During the session, the therapist was actively listening, she appreciate all the information that I gave her ihe other clay she already applied for unemployment and went to welfare at least is quieter. Has encouraged to increase thase negative thoughis for a positive once, we started to work with her problem Response‘feedback: . Evelyn was very attentive and was quiet and relaxes, Progress Note Dated July 18, 2019. R. 992-93. Chief complaint: looks bener, referred that she fas been doing berter at least hay been sleeping berrer ond har been fess curcicus. “ MOOD CHECKING __(0-10). DIARY CARD OR COPING CARD? Yes__ No_X BRIDGING: About the psychiatric appointment” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL BEHAVIOR? Yes__No_X_ THERAPY INTERFERING BEHAVIOR? Yes No X SKILLS? Yes__No_X AGENDA: I would like to talk how | will be dealing with this situation because now I am very negative“ ABC OR CHAIN ANALYSIS (VF. PE. LINKS: COGNITIVE. EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME. CONSEQUENCES: IMMEDIATE, DELAYED):. A- “I am doing better but my health is not well, 1 continue with a lot of pain in my hip and leg” B-“T think this will be a failure, I think that I am going crazy, I think that I have something bad and the doctors doesn't want ta tell me nothing" C- "I'm feeling less anxious two times a day every day, less depress” DIAGNOSIS; (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention: During the session, the therapist was actively listening, she appreciate all the information that I gave her the other day, she already applied for nmemployment and went to welfare at least is quieter. Was encouraged to increase those negative thoughts for a positive once, we started to work with her problem Response/feedback: __. Evelyn was very attentive and was quiet and relaxes, Progress Note Dated July 25, 2019. R. 990-91. Chief complaint: Evelyn looks better, referred thai she has been doing hetter at least has been sleeping better amd has been less anxious is taking the medication regularly , this afternoon I will go to Florida with my midwife, [ think that will be good for me” MOOD CHECKING___$___ (0-10). DIARY CARD OR COPING CARD? Yes__ No_X BRIDGING: About the psychietric appointment” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL REHAVIOR? Yes__No_X_ THERAPY INTERFERING BEHAVIOR? Yes __No_X SKILLS? Yes__No_X AGENDA: would like to tatk how I will be dealing with this situation because now I am very negative “ ABC OR CHAIN ANALYSIS (VF. PE, LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME. CONSE QUENCES: IMMEDIATE, DELAVED): A- “lam doing better my health is better and I am sleeping better, I will go to Florida I hope to have a nice time” B-“| think this trip will be good for me because I been in a lot of stress” C- "I'm feeling less anxious two times a day every day, less depress” Ae gS EE SIGE LEDUC EEN REET misRtasa se ar Fe coins sessed cave al Benen ERE ra DLAGNOSIS: (296.26) 33.1) Major depressive Disorder, Recurrent episodes Intervention: During the session, the therapist was actively listening, was encouraged to change thase negative thoughts for a positive once, was talking about her health problems but is not aniythinng That baci, was explained how her thoughts affect her feelings and the way that vou see the life . Response/feedback Evelyn was very attentive and was quiet and relaxes. Progress Note Dated August 02, 2019. R. 590, 988. MOOD CHECKING From one to ten , chit day | feel maybe 6 COPING CARD? Ha BRIGHSING: “The last session we were talking abowt my inetionals thoughts and how to be change it for a positive once, that day ¢ wes going to Florida .* REVIEW OF HOMEWORK (WHAT DID VOU LEARN): [ had a nice time in Florida , i enjoy thal momen there” Agendas been in stress fer those economical issues that i have and i don't know what to do want to talk bow to manage the stress ASSESSMENT: A- “I am not well, my bealih i atthe same , | went to Florida the last week . i enjay thee wip but i feel the same specially because the economical problem are getting worst *8."1 think this will beso bad if! continue like that I will need a sungery but will be worst.” C-" I'm feeling very anious two orthres times a day every day , very depress and crying for no reason two or three times a day." MSE: General Evelyn appear nervous , with sad affect , oriented M3, well groomed , good insight and judgment - DIAGNOSIS Major depressive Disorder, Recurrent episodes (2962/ P-33) Intervention During the session, the therapist was actively listening, was encouraged to change those negative thoughts for a positive once, was talking about ber heaith problems but is not anything That bed, was explained how ber thoughts affect her feelings and the way that you see the life About how to control the stress we were working with mindfulness excroise, she did very wetl Responserfordback Daring the session was at the firs very anxious but after the mindful exercise was quieter , was strongly reinforced because of that Progress Note Dated August 5, 2019. R. 845, 986. MOOD CHECKING COPING CARD? No BRIDGING: “The let seasion we were lilking about my araiemals thoughis and how wo be change it for a positive ance.” REVIEW OF HOMEWORK (WHAT DID YOU LEARN) To de honest, | did nothing al the weekend Agenda Encourage patient to madcen dist of whet he or she wdepoessed about and discuss list with therapist ASSESSATENT: A - Every single day i feel the same , bat iam very weery for my eeonomical situation Because Lam mot working B-T think thats ama hacmuse fem noe working "e-T fas) eud.every single day, mciousand very unset ond anger evary dey! MSE: (General 2velyn appear ancieus , sed after. was tearful onented i163, miocivated to continue the sessions TP ocpenised , pood insight and judgment DIAGNOSIS (F330) Major depressive diacedey, receremt, mild Intervention Duning the sesmon was active iisteana her expressung her feelings , was validated because ts normal that she feels like Shat and hawe that hopelexsness feeling was encouraged to talk with the psyciuate about ber feeluags to review medicazon Encourage the replacement of megane and self-defeating velftalk with ceabeue and powtive cogmtive evessages. she thank that she ot a Paclure avd because she have all leer bells back deeb wert to the SS] office she want to do it thas day Respomefeedback When we started the seenon she was tearful and overwhele but afer the seston was quieter and xmiling was strongly reuvforeed ond was veladated Progress Note Dated August 13, 2019. R. 847, 984. MOOD CHECKING From 1 to )0] feel maybe 7 COPING CARD Nia BRIDGING: “The lest seaion we were talking abow! my irazor’s thoughis , my peychiaiee appointment , oy fealth peoblems and how to deel wah my sired.” REVIEW OF HOMEWORK (WHAT DID YOU LEARN "I ty to be weeking changing my meget e thougie: every time those Hit my cnind , times is hard because ta very diffieult." Age nel ASSESSMENT: A- [am doing better at least] fivd help to paid the morgage and the other bills. evy sonand my beother helps me but tts hand "Be ] ‘think (fi coettimwe Like that (will decease because thatis very sressfal " C-T fee very sad, aikeas , 18m mot seepEng . MAE: General Evelyn has been worry affect depreas, mood anmous oriented 3M , pore inmelt ead pudem ent DIAGNOSIS (F-331) Mayor depressive disorder, recurrent, moderate Intervention Dung the sesmon he way aciive bstening . Was Valdited be feelngs and we were ew almiag how she id to pay all hes bulls, were evaluating how she has been doing with her medkcal comdbtions , she had an appowtment thus day and tacy saad that, Respomse/feedback During the session wus quit alert and cooperative Was resnfocoed possbve because of that * — 10 — Progress Note Dated August 29, 2019. R. 856, 982. MOOD CHECKING From 1 to IM this day [ feel COPING CARD Ni BRIDGING: "The let session we were Gilling about my mratmals choughis and my health problems." REVIEW OF HOMEWORK (WHAT IMD YOU LEARN): To De honest, | did nothing al with methong beemuse ,[ been in pam | Agenala T want to talk about the sppeuntivent to the cardiologist. ada am heaing:a bed pon nmy reght arm. ASSESSMENT: A° Tam wotry, fecsuse Tarn having rapid heart bits and this day Twa to see the cardiologist Ee" [think that Uhawe heart proolems and they don’t find noting” C: "T feel snd, very worry, sometimes frustrate" MSE: Evelyn has been worry affect depress, mood . orvented 36, god insight ad judgm ent DIAGNOSIS (F-331) Major depressive disorder, recurrent, moderate Intervention During the sermon she was tallang about her health peoblems, she thinks che has something wrong, weve weekang wrth her wrationals thoughts because she ood an stress test done and Elecrocundogrim and cacie out [ine Dut she hax to connue weekang on tt bryig to be out sires: * Respeme/feedback During the seston was qucet ind poor i latwe CBE Dated September 5, 2019. R. 592, 980. MOOD CHECKING Prom 1 to 10, ifeel 6 COPING CARD? Na BRIDGING: *The last sesacn we were talking about my grabonals thoughts and how io be change it for a positive once,” REVIEW OF HOMEWORE (WHAT DID YOU LEARN): Ta be bonest, I ded nothing at the weekend Agenda “Evelyn wants to continue working with thoughts replacement, “Increase her coping skulle.” ASSESSMENT: A-“I been feeling better bat [ know that | om very negative sometimes” B-* I think there are times when I attuctregabve things [thank with heakth problems I will mot be able wo work ewer * C- “that sitzation makes me feel bad, sad and] dom't want to be soound no one two three times.a week and J feel sorry foe my faenily . they do notdeserve it “ MBSE: APPEAR WORRY | WITH SAD AFFECT MOOD OR , TRORGANLZED GOOD INSIGHT AND IUDGMENT . DIAGNOSIS Major depressive Disorder, Recurrent epodes (296 2/ F-33) Intervention During the session, the therapist was acuvely listening her talking about the results, was validated because she has been dealing with th situation very well but she has to continue working changing negative thinking foc a passive once also it was oriented that when those thoughts of fe come to your mind changes & for another different and positive as that she will not go to work in her life Respomse/feedback During the session was quiet and cooperative but with hopelessness feelings — 11 — Progress Note Dated September 13, 2019. R. 978-79. Chief complaint: Evelyn looks better, referred that she has been doing benter, said that she called to the social security office and she canceled the disable application and she wenl to her fob to see when she will start to work, fant not feeling well jet ina I need to work because all my ills are behind, think that will be good for ine fo start something “ MOOD CHECKING _7__ (0-10). DIARY CARD OR COPING CARD? Yes__ No_X BRIDGING: About the psychiatric appointment” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): . SUICIDAL BEHAVIOR? Yes__ No_X_ THERAPY INTERFERING BEHAVIOR? Yes __No_X SKILLS? Yes__ No_X AGENDA: I would like to talk how I will be dealing with this situation because now I] am very negative “ We will be working with the treatment plan for the next 120 days AURA ER TERT ABC OR CHAIN ANALYSIS (VF, PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME. CONSEQUENCES: IMMEDIATE, DELAYED). A- “lam doing better my health is better and J am sleeping better, soon J will start to work" B.“ Twill start ta work soon but Il think will be good but at the same time I think that I couldn't do it " C- " I'm feeling less anxious two times a day every day, less depress” DIAGNOSIS: (296.2F/ 33.1) Major depressive Disorder, Recarrent episodes latervention: : During the session, the therapist was actively listening, was encouraged to change those negative thoughts for a positive once, was talking about her health problems but is not anything That bad, was explained how her thoughts affect her feelings and the way that you see the life. We were evaluating the treatment plan for the met 120 days. were evaluating the progress and the bapartance of seaileely ho nie theron sections and confine regnioriy the pevohiatric treatment: wae cchaduls a pevoliatcic appointment for the mest Jem. Response feedback “ Evelyn was very attentive and was quiet and relaxes. — 12 — Treatment Plan Dated September 13, 2019. R. 849. Diagnosis |_| Major depressive Disorder, Recurrent CODE: (296.20 F/ 33.1) dicate Specific Stressors Economic problems , medical issues Client's Strengths (Use the one in the I-Good motivation for the treatment, good insight , motivation to keep Recovery Goal): vorking Challenge to Treatment: decrease her social activities, increase freq to therapy sessions Anticipated Length of Treatment: Months X-6 Momths (6-9Months (9-12 Months Unknown For Update Only: (Review of Progress since Last Plan): During the last 120 days she gad some progress , her health is better and that situation emotionally make her feel bevter CONCERNS -1(What client states problem is, activating event, beliefs, emotions, behavior, relational problems, and somatization): Evelyn ABC'S: A“Tam doing better my health is better and J am sleeping better, soon f will start to work" [will start to work soon but J think will be good but at the same time J think that I couldn't do it” C. Jn jeeling less anxious theo times a day every day, less depress” Long Term Goal / Discharge Criteria (What will be accomplished by the client at end of treatment): Evelyn will improve her emotional control and will return to a normal life following the clinician directions . Short-term Goal: (What will be done over the next 4 months to achieve long term goal.) !- Deerease the level af the BDI-II (35> Severe Depression to 30 moderate depression Jand the BAI from 2] moderate to [9 2- By the next 30 days Evelyn will be seeing the psychiatric to continue with the medications. Progress Note Dated September 16, 2019. R. 864, 976. MOOD CHECKING From | to i), i feel 6 COPING CARD! BRIDKGING: “The las session we were Lilking about my arationals thous and my heahh peoblems," REVIEW OF HOMEWORK (WHAT DID YOU LEARN) Te Se honest, | did meting al the weekersd Agenala Thas day 1 have prychintvic apomahwent would bo talk ateot Thas day j would |dce totalk about Atout orational thoughts Wilida tion of hes feelings I want totalk about mey feors ASSESSMENT: A- Tis vragkend! woes end, rust lay fd but se Sunday ean my deugirier fut gee riot well” 7 demi Gaines eet ever vel] dis what i thought. i because | want hoostart to work? - Tfee sed, crying a lot. more than te tines a day. Lau not even sleeping well" MUSE: EVELYTRM APPEAR WORRY , WITH SAD AFFECT , MOOD OR , TP ORGANTZRD GOO INSIGHT AND JUDGMENT DIAGNOSIS (F321) Major depressive diaocdes, single episode, moderate Intervention Dunng te sesmon, the therapist was actively lterung to ther fears, about everyiung, wat encouraged fee these days prepare activ dies for the family . they could spend tone logether . go shopping of Coos, get a pel logether. try to spend the sovt tome logeliver without agumentation sive has 10 work her negstive Yrought, wae mstructed to think in postive because a9 cove negeuve thoughts we worte every time a megatwe Tunking hut her raind honk somethang poastire, Response/feedback Evelyn was acuve coopersive and talkative , was strongly remifonced — 13 — CBE Dated September 27, 2019. R. 594, 974. MOOD CHECKING From 1 to 10, ifeels COPING CARD? No BRIDGING; "The last sesaon we were talking about my grabcnals thoughts and how to be change it for a pasituve once,” REVIEW OF HOMEWORE (WHAT DID YOU LEARN): To be honest, 1 dad nothing at the weekend, was so sad , jwas 2t the funeral of the grandmaofmy children, a panic attack when i sw her Agenda would like to talk about my emotians ASSESSMENT: the lathe Ist weekend was the funeral of my ex mother in lew sd it was surprise" think 1 should be closer to her because she was very supponive with me °C] feel very depress , thinking to much, i am not sleesing MSE: General Evelyn appear woety , sad affeet, anes , cooperative , oenied XS , good iceaght and judement DIAGNOSIS Major depreseed disorder , recurrent Intervention Dizing the session, the therapist was actively listening her talking about the situauon of her sister, was validated because she always ha been there for her and more and thas isa good walue of her. About the negative thought, she has to continue working in that, was encowaged to keep: record of her thoughts , positives and negative once in & erent situations, the negatve thoughts usually are not good fcc the emotions. About the feelings about the death of the ex mother in. Jaw , were working rational thinking because she was sick and and was a very old person. , things happen and you can't change nothing , just give support to her children and the rest of the family . Respome/feedback She was cuict alert and cooncrauve Progress Note Dated October 03, 2019. R. 972. MOOD CHECKING Frees 1 to 1, i feel COPING CARD? Ne BRIDGING: we were tulking abet oty smother in law death” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): To be honest, I did nothing at the weekend Why sometinics | am moody in the momning for no reason”, ASSESSMENT: A:" Mostly in the mamings I feet moody apd | stay anxious and sad the whole day. B:" 1 think there is no reason to be like that ldo adhe not resolved C:" | do feel anxigus or depressed. { do feel nervous, worried and I do not want to do nothing. Sometimes | MSE: General Evelya appear worry , dad affect, anxious , cooperutive , orieated XJ, good insight and judgment DIAGNOSIS Major depressed disorder , recurrent Intervention Therapist maintuined active listening while she shared about her effort in dealing with all ber issues. Therapist and patient discussed about sorting out task and prioritizing the task and completing It one by one. Therapist educated patient shout how she coald help her son 40 be more responsible, because can't be up and down Evelyn has to learn how to say no. Responte/feedback Evelyn was quit alent and cooperative and was strongly reinforced because she bas been doing well Progress Note Dated October 09, 2019. R. 596, 970. MOOD CHECKING From 1 to 10,1 feel 6 COPING CARDT No BRAGGING: In the last aecsion we were talking bow to manage the etregs for my econoenical problem , i dan't have mo po, no income REVIEW OF HOMEWORK (WHAT DID YOU LEARN): "I try to be working in my situations but is to bard tobe into" Agenda 1 feel so bad , i can't finda job, have another mooth of morgage, ght and everything i den!t knew what to do“ ASSESSMENT: A- 1am very overwhelmed i can't find a job, i dan't have oo answer from anywhere and iam very tired “ Be 1 think my Life is a disaster, jam tired of everything , everything goes wrong for me.” C-1 feel so bad, very depress , frastrate and very anxious MSE: General Evelva appear worry . cad affect. anxious . coonertive . onented 43. mood insight and jmdsment DIAGNOSIS (F331) Major depressive disorder, recurrent, moderate Intervention During the session Evelyn was active listen when she was expressing her feclings and was validated because the situation is not cary we working problem solving helping her to find some economical help , was gives a telephone number of Usep Help with bills , if che can't reach them by she has to go downtown and try to contact them , they help with bills also we gave her the information of philadelphia legal assistance to find belp for heat and gas , any public benefits , also we called to logistic care for the day passes to could move easy in bus . Reeponsfeedback During the session she was quiet and cooperstive . — 14 — Progress Note Dated October 14, 2019. R. 598, 960. MOOD CHECKING From to 101 feel & OOFING CARDT ho BRINGING: “The last cestion we were talking about my inrationala droughts and how to be change it for a positive once." REVIEW OF HOMEWORK (WHAT DID YOU LEARN): To be honest, 1 did nothing at the weekend Agenda She wants to tuk about the stress in the family ASSESSMENT: A-"Evelyn came to the conicr today for therapy session, she looks sad and with low energy. B- Byelyn had reported in latest aession her health and her financial problems, she said thet those are tho mainly reason for her wm feel depressed. C- Today she continued talleanig abscourt heer family stress and about being aguressive lately: “Ie this week C was arguing with my daughter anda feet sorry Ieecamse she is pregnant , Soenetines | have poor self-control on my anges, ales Lam having a lot of arguing and disagree with my farily. Evelyn reported thet she is having between 4 and 3 of dleep every night. MSE: General Evelyti appear worry , snd affect, amdoud , cooperative , oriented 23 , good insight and judgment DIAGNOSIS (F331) Major depresiive disander, recurrent, madecale i i i i i of goestions. Abust Intervention Following the agenda we continue the psycho-educalion she was talking about she understood and was matcing a bot of qu the conflicts that he is having , were exploring what is happening and what why she bes been feeling like that , wos explained what it □□ solving sirmegics and bow will have tobe done staring when you define the prublers fotowing for cevelop mvaleiple solutions , in this case knowing , accepting and adjusting difference . In role play she was showing us the way that she talk with ibe family, was encouraged to change some things. She was alto assisted on use altemative thought find a solution for her fnancial situation. Responseierdback During the session she wag quiet und couperative . Progress Note Dated October 24, 2019. R. 868, 966. MOOD CHECKING From ome to en I feel COPING CARD? BRIDGING: “The last session we were lilking abot my inrateimes thoughils and how oo be chine 1b fer a positive) once.” REVIEW OF HOMEWORE (WHAT DID VOU LEARN: Te Se hanes, | did mening at the weekeral T weal Ibe tis talle how T wil] be desling wrth this sttustion because ] an very negebye * ASSESSMENT: A- “Tony doing better meats a net well, if] commas werh this pain andthe cold symptoos need to go to thie emergency thinde thes will fe 2 feature, think ehat [gum goiner eraey, [ tunik that] have soqwething bad and the deetors deesn’t went to tell me sothing” C-"T'm feeling very ercioustwoor tree duy every day, very depres¢ and crying for qm pressor tee or Tee Ties a day ~ MISE: General Eyelva looks wer, affect depreted cond angry and very upset OW good ineight and judgment DIAGNOSIS (2545 335. 1) Mapar depreasve Cisonder, Recurrent epacdk= Intervention Dering lac sramon, Loe Ueerapie, wet aclwely lostenag hur bebeang, 290) Le silizition, she could identity sone rational tous as “Aloaye □ have fo be sick “was expunirii her bealilt peoblesn and haa reasons for ber Hopeless feeling but wae encouraged to charge that thought for one o8"L have thie problem but is met something that I will died for it becamee Dara dealing with for a long time” Respanelieedback wae liters bit Gustrate atthe first but late on was different, very attentive and wae quot arte relaxes — 15 — Progress Note Dated October 29, 2019. R. 964-65. Chief complaint: so baa, Jam coming from the doctor affice, [can't even walk with my back pain and now is worst, and the last week was a hae cold and mow this," MOOD CHECKING 5 _ (0-10). DIARY CARD OR COPING CARD? Yes_ No: _X BRIDGING: I don't really remember” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): I don't remember E been so bad" SUICIDAL BEHAVIOR? Yea Noe X_ THERAPY INTERFERING BEHAVIOR? Yes __ No_X SKILLS? Yes_ No_X AGENDA: | would like to continue working how to control those irrationals thoughts and mvy fears because my health don't let ve think different” pbetine as poss ah ae Suan, ea a euNeronemne eee ABC OR CHAIN ANALYSIS (VF. PE. LINKS: COGNITIVE, EMOTIONS, ACTIONS, SENSATION, EVENTS. PROBLEM BEHAVIOR: WHAT, WHEN, HOW MANY, WHERE, WHAT TIME, COMSEQUENCES: IMMEDIATE, DELAYED): “Dam noi well, my aps and downs with mp health are driving me crazy “ Be “chink shor J am a disaster when is not one thing is another “ C “Pin feeling frustrate, feo or three times a day, sad ewery day 24/7 , and crving soretimes” DIAGNOSIS: (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention: Ouring the session, te therapist was aetively listening her talking about the situation, She has to be thinking about sonthing bad could happened, Was encouraged to follow the instructions of the doctors calling to the offiee to put fhe shot in her back, if she need it she need it; She has to investigate what is happening to her ana why she has fo be fike that always. Response / feedback. wos litters bit frustrate at ihe first bur late on was different, very attentive and was quiet and relaces. Progress Note Dated November 11, 2019. R. 873, 962. MOOD CHECKING From | cen] feel COPING CARD? BRIDGING: “The lest session we Were Lalcing abou my iralionels Louis wd how lo be chaee 1b bor a positive once.” REVIEW OF HOMEWORK (WHAT DM VOW LEARN: toy te be werkong in my sitisttieds Sut ws io hard to be mm be * Agenda ASSESSMENT: BASIE: ral During the session Sie was quict alert and cooperative . affect appropriate . good inayeht and judgerent MONS (25 27) 33 1) Major depressive Cysorder, Puecurrent epaacdes Intervention During tre seamed, tre therapiet wee achvely eterno her lene soul the situntien, she could idenbihy sete ination! theists as “Always l have to be stick “was explaming her health peoblesn and hes reasens bor her hopeless Jeelog bat was encouraged to change that thought tor one wT have thiv problem but i cet something thee] will died for 11 becauwe Darn dealing with for a long ime* Responseffeedback Evelyn was litters bet frusizate at the fiest Gur labe om wis diferent, very attentive andl wire queel and nelawes — 16 — Progress Note Dated November 18, 2019. R. 960. MOOD CHECKING From 1 to i), Tieel 7 COPING CARD? BRIDGING: "The leat setaion we were talking about my irrationals thoughts and my health problems." REVIEW OF HOMEWORK (WHAT DED YOU LEARN): “l try to be working changing my negative thoughts every time thase kit my mind , sometimes very difficult , at least i weet to apply for help light beat Agenda T want to continne working restractaring my thoughts” ASSESSMENT: A- | trying te do the best ican , but sometimes i ame very negative * Bel always thinking that i will nut find any help * C- L feel depress, sometimes very anmious is like alway scare io panic” MSE: General Evelyn appear worry , sad affect, anxious, coapemsive , oriented X3,, good insight and judgment DUAGNOSTS (F331) Major depressive disorder, recurrent, enoderate intervention Ding Se sets Se woe nas Leiner ney pet te ete te pea afm bt he stu i did it t a ys ' ies a acne tbe emolian that come befare the thought and them Cheek how accurate and usefal the thought ir and the ead change the theught to a more helpful one as ResponseMeedback During the session abe was quiet and copperntive . CBE Dated November 26, 2019. R. 600. MOOD CHECKING From 1to 10, feel 7 COPING CARD? Na AIRTDGING: In the last sessacn we were tellong how to manage the tress REVIEW OF HOMEWORE (WHAT DID ¥OU LEARN): "1 try to be working, in my sthuatoons but is to hard to be mito" Ageoda [need to cont working wilh my irationals thoughts ASSESSMENT: A-1 been doing everything to be better or wel! but the situation is nateasy " B-1 think , sonehmes my wellness is bersuse something bad will happen" C- 1 feel bed, , very ercuioes all the tome , Lalways think too mich , eumetines 1 con skep well" MSE: General Evelyn appear worry , sad affect, arcwous . cooperative. onented XS , good insight and judpment DLAGNOSES (F431) Major depressive disorder, recurrent, moderate Intervention Dummg the session, the therapist was achvely listening, was encouraged to mcrease those nepwhve thoughts for s pastve once, we Started to work with her problem solving first of all she need to call to unemployment because she could apply and they could help her with the 80 oF G0 of her salary , another thing , not everything is bad , the program of the light heat and gas pay off my debe ot least is something aral was aporeciated our help Respomselfecdback Evelyn was very attentive and was quiet and relaxes Progress Note Dated December 19, 2019. R. 891, 956. MOOD CHECKING From iw i feel’ COPING CARD? “The last seo we were Gilking aout my drains thous and how to be chame 10 bor a poet] once.” REVIEW OF HOMEWORK (WHAT DID VOU LEARN) “T toy ls be weeking in my sttunitiess Sut esto herd tio be im bo * Agenda T would like to continue taleing about the situation tat jam having pow Eduecution shout the sstustson of fer health " ASSESSMENT: A- 2 am tring to de the best but my Aealth amot well , now the dre that i need sumpery © B-T think if t have the surgery i wall not be te same sgmin' (7 fee) weeny every single day, eryrig faethe most simple fim, ad letengeht | ves up aleaeet the whole magi" NESE: General During the session Evelyn was quiet alert and cooperative poor suaght and judgement DIAGNOSIS (F351) beior depressive disorder, recurrent, moderate Interveotion Therapist worked wath Evel poaching achve listerong amd validating ber feelings, we start to talk about her fears and her wornes she saad thal se bas been seeing peodbe that lacy did) peed after Live sungery all another nae been ded . wis valdited because os ine bul aleo she las a loted people who has done well and the auprowement un the bealth is huge. was encouraged fo Keep the appeunten ent becwue that's the ceagon of that oppoitignent , It a-orientaiion. Evelyn was motivated to comtice with the proces to ane whit. is polig to be. Response‘feedbach Evelyn was very alientive and wes quiel terfal acl very angry in coment — 17 — CBE Dated January 6, 2020. R. 602. CHECKING From ome to 1th, i feel this dey 7 COPING CARD? Nao BRIDGING: In the last sessaen we were talking how to manage the stress REVIEW OF HOMEWORE (WHAT DID ¥OU LEARN): To be bonest, I ded nothing at the weekend Agenda | would like wotalk bow | will be dealing with this situation because now | an very negative “ ASSESSMENT: A- “I am notwell, my health isnot well, | bad 2 cortisone injection again , bat the pam sill there. * B-"T think this will be so bad of like that [ will need o-surgesy but will be worst.” C-" I'm feeling wery anxious twa or three Gmes a day every day , very depressed and cryin for no Teasan two of three times a day." MSE: Evelyn appear worry , sad afivel, ansous , cooperauve , oenied 3, good ineaght and judement DLAGNOSIS (296.25 33.1) Major depressive Disordes, Recurrent epootes Intervention Duming the sessvon, the theragist was achvely Lisening, she appreceste all the imfcamation that 1 gave her the other day, she already for unemployment and went to welfare at least is quieter. Wes encouraged to incense those negative thoughts fora positive ones, we started wartk with her problem Responseferdback Evelyn was very attentive and was quiet and relaxes Progress Note Dated January 22, 2020. R. 885. MOOD CHECKING From ome to ten i feel 6 COPING CARD? No BRIDGING: "The last session we were talking aboat my irmtionals thoughts and my health problems.” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “L try to be working in my situations but is to hard to be in to” Agenda | would like to talk shout my fears How to change my negative thoughts for another once mone productive Analiey and program what will be ‘the next treatment plan For thee eect 12) days i be i i " i ould herve me in ASSESSMENT: A-! been soars because the dr said that i oeed a back surgery, ey pain is affecting ery kite ' think that surgery om a wheelchair" C- I feel depress every day crying two or three times a day , always thinking the worst , sometimes 1 can't stand still walkieg back ond forwand two or three tines a day" MSE: General Evelyn appear worry , sad affect, amaious , cooperative , oriented 25 , good insight and fudgroent DIAGNOSIS (296.26! 33.1) Major depressive Disorder, Recurrent epaiodae rrentl i i iwely listening to theie fears, even though the results cume oul negative she continac thinking ie ee ne ae the doctors ifthey decide the surgery is because is the best option but befpre that she has to talk with the drs , they explain her the pros and cont of the eurgery , we comtime restructuring her cognitive pattern , was cantirmed that everything is fine with beer, she has to continue working in that pact, changing those negetive thoughts fara positive ones. ‘Was seachedule the psychiatric appomtment for OVA Reepensefeedback Evelyn was very attentive and wos quiet and nelaces. — 18 — Updated Treatment Plan Dated January 22, 2020. R. 875. Dingnosis ( please add the DX) (F330) Major depressive disorder, recurrent, miki, General anxicty disorders Fal! Undiewte Specific Stressord) Her medical iseues , economical issues due she can't woek due ber medical issues , is wailing for a back surgery Strengths (Uae the ome in the Recovery Goal): Motivation to continue in treatment , good femily support ayabemn Challenge ta Treatment: locrease ber social aclivities Anticipated Length of Treatment: 3-6 Tehanting For Update Only: (Review of Progress since Last Plan) Describe progress During the last 120 days Evelyn had some progress, dhe went to different programs Jooking for help and she got it, applied for thee ‘S81, but the lewel of anxiety and depression increased becouse is waiting fora call for the schedule for the lower back surgery CONCERNS -1( hat client states problem (5, activating event, belief, emotions, behavior, relational problema, and somatization) A. [heen betaase the drsaed that i need a back surgery, my pain ia affecting my knee" 8-1 think chat surgery could leave ene iin a aheelchair ™ C- I feel — day crying two or three times a day , always thinking the worst , sometimes i can't sfand still walking back and forward two or three times a Long Term Goal! Discharge Criteria (What will be accomplished by the client at end of treatment) Evelyn will develop the ability to recognize , accept and cope with feelings of depression for the next 120 days Short-term Goal: (What will be done over the next 4 months te achieve long jerm goal.) Evelyn will reduce the scare of depression and ansxlety in the Beck questionnaire froma 35 to 25 severe to moderate in the next (20-days Evelyn will reduce the freqeency of cries at once or per doy . Evelyn will identify at least one negative cogmities eelf talk that @ involved with her depression symgtoma Modality including medication management & Responsible person Will be working with Evelyn in individual therapy in the modality of CBT and will be eehedube a payehlainic appointment every monsh im monitor medication Interventions In jedividgal therapy we will |, Combine the peycho edweation to tech to her bow the health problems affect her emotions. 2- The therapist will assist Evelyn about develops an awareness of her cognitive tmeseage that reinforce bopelessness and helplessness, }- The therapist will educate her abot her medical problems. 4~ Use real bogic to challenge ench dysfimetional thought of negative thinking patters accorsey, replacing i with a positive, logical thought, □□ Elaborate plan ef different healthy and pleasant activities to develop in the next 4 months (Fehavir Activation) fWork with thoughts replacement negative for positives. 3 C's techmigoe 7-Validation of ber feelings , and prog and cont .and mindfulness exercise Progress Note Dated January 28, 2020. R. 883. CHECKING Fron one to ten, i feel § becamae jam tired but happy granddaughter was bom on Sanday * COPING CARD? Mo BRIDGING: We were taking atoul my bealth situaGen™ REVIEW OF HOMEWORK (WHAT DID YOU LEARN): | am trying te do what i hove to do bat some tienes is to hard” Agenda | would like to talk how J will be deoling with this situation becauac now | am. very negative . The therapies will help Evelyn to implement a ‘cognitive restructuring utilizing the 3 C's technique. ASSESSMENT: AJ been.so bugy , i alresdy hawe my new prondbaby , it a baby purl, is so pretiy and i been very stressful BAT think that i can't deal, wath a ctrees because becaase i work in show motion i feel better but i will warty , amtigud.and sometimes | don't kmow what to do.” MEE: ‘General During the sesshon j was quict abert and cooperative , good insight amd judgment . DIAGNOSIS (2962F/ 33.1) Major depressive Disorder, Recunrent episodes Intervention During the session, the therapist was actively listening,ehe was so excited because hermew granddeughier was born , was validated she is doing well , was she appreciate ofl the infoematiog thet | gave her the other day. Wes encouraged ta increase those negative thoighdis far a positive ooo, we started to work with her problem . she will be practicing the 30's technique identifying the thoagh: before the emotion and them change 4 for another ome more productive ani). positive. feedback Durag the acaaion was quiet alert ond coopermlive, was reinforced positive for it. — 19 — Progress Note Dated February 07, 2020. R. 881, 897. MOOD CHECKING From one to ten , i feel 6, ny brother is af the hospital and he is not well COPING CARD? Na BRIDGING: We were talking about my health sttuation , i waa afraid for the possibility of'a surgery" REVIEW OF HOMEWORK (WHAT DID YOU LEARN): 1am trying Agenda | want to talk about my situation , i still out ofa job and biter bit-abeat my brother * ASSESSMENT: A- Evelyn is worry because che needs to fined a job and is cerry for her brothes™ BT chink he will net going te-make it this time, ] see him well” C." Pin feeling sad three or fiver times aday ,wony foe my brother every day , and arcions almost two tines a day for around an MSE; General During the session Evelyn was quiet alert ancl cooperative poor insight and judgment DEAGNOGIS (F-331) Major depressive disorder, recurrent, moderate Intervention During the seasion, the therapist was actively listening her talking about the situation of her brother, he had an stroke aed bee ie in care , was validated beceuss ale always has been there for bin and more and that is 2 good value of her, About the negative thong, che has to continge working: in that, was encouraged io keep a record of her thoughts, positives snd negative once in different situations, the nogative thoughts usally ane not good for the emotions. Responsofeedback Mara was very attentive and was quiet and relaxes. Progress Note Dated February 13, 2020. R. 879, 899. MOOD CHECKING from one to tent oy brother still been the same COPING CARD BRIDGING: "The last session we were Lalking abowt my irralaels thous and how to be change it for a positive once.” REVIEW OF HOMEWORK (WHAT DID YOU LEARN, Te Se hemes, | did mething ab the weekeral T would dike tp talk how T will be desling with this situation becnuse mow an very negabye * ASSESSMENT: A- “Tam mot well, my Tealth ianet well, [ hed a eeotisome injection again butthe gaan ati] there.“ B-"T think tia will be ao bad i deat know whiewill peers he vero "Ths feeling very secs fee or Sree times a dey every dw very depressed and oryryg for ns rensen Two thee tines a dey, MISE: Drunieg the session Betlyn was quiet alerland cooperative poor coelil and pudeetieat! DIAGNOSIS (F-331) Majer deoressive disorder, meucrent, modersic Intervetion Dhrins □□ seman, tae Uaerupis. was aclively taster, was eareuaged Ww ancrease those negabive Gwupcts for a pemive ance, ws about er health proghema but is wot anything That bad, war explained how we will goto be working to conirel her panies Respennteedback Evelyn Was very alleniive aad wks quset and relaxes Progress Note Dated February 17, 2020. R. 877, 887, 916. MOOD CHECKING From one to ten, i feel & COPING CARD? Mo BRIDGING: During the session we were talking how to control the siress about my bealth situateon * REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “Lam trying to do the bes of | can bot sometines fs 00 hari” Agenda We will be working thought restructuring with the 20s technique Validation of her feelings ASSESSMENT: A- Tam trying to be better bot my health contimas at the same my knee is harting » lotamd eny brodher sow is ina recovering bore B- [think that | am net going to be: like that forever" C- 1 feel bad, sod, frostrate , very anxious sometimes in panic end that is two or ihece times a day a MSE: (General Dising the session Evelyn was quist alert and opoperative poor insight and judgment” DIAGNOSIS (F-33 1) Major depeesive disorder, recument, moderate Intervention Dearing the session sho was active lisicn when abe was describing her feelings , she is mod Feeling well bet was valicated because if she tee forward she is having good improvement , she has been doing a lot of positive things, but has to ¢omtimie working with this tituation now . this day will be working with the 3 Cs technique. evalieh the emotion before the thought and them cbeck if'that emotion that gemerwte the thomght and (Pit is ‘beneficial or useful for her ond ber health aed them change it for another one mor positive, she is having those oegative thoaghts but that ig mat for her and ber health.She has to think that her brother will be better and abe is doing everything to be im a better comdition - Responsefeedback During the seasion she was very attentive ot the end waa quieter and more rolex. — 20 — Progress Note Dated February 28, 2020. R. 918. MOOD CHECKING From one toten. feel 7 2 been doing better COPING CARD? Nis BRIDGING: The last sexieon we were talking 2oul cay negative Ghoughos becwase the saluation of my brother" REVIEW OF HOMEWORK (WHAT DID VOU LEARN J been cere 2 let of chengs to ave sy chimes well * ASSESSMENTS A: "Tan feeling less degressed. Still working with avy daughter but notion mich beemuse my henth poolslers Bs "TD belvere thot] get batter ntmunmingang my Chinbange” Co: "Tosti get denrensed teen ot tee tes day □ General Svelyn nave a aad affect. moed at tee same , poor grooming , onented 43, good insight-ad judgment DITAGNOSIS (20.2 F-34.1) Major depressive Disordey, Recurrent episodes Intervention The therapist conboued to work with Evelyn on dentfying and cooing unhelpful thoughts. Evelyn warvalidated she hes been doing better , she os deny some yoo, that's a good step Dor ber, was encouraged wo see how she start aml where the she understand and eee that but the nopative thoughis are been Very odie. Wee cocouraged to uncceaee to The meceaary support and cneouragenent were given during season. was a relaaation exercee with positive thinking exerciag Responsefeedback Evelyn mapense very quiet and pesiine and was noinforoed postive and wean encouraged to continue like thet. Progress Note Dated March 2, 2020. R. 920. MOOD CHECKING From one toten . i feel .maybe 6 becouse i received.a paper irom the S38] and that stuation ovakes me fie] wy bea COPING CARD? Na BRIDGING: The last sessvon we were talking 2o0ul my negative thoughis REVIEW OF HOMEWORK (WHAT DID VOU LEARN ] been domg a lot of thongs to Save oy things well “OMG i doctt know what to do when i all those pagers Agenda T would like to tall about, whatawoll do woth all this papers . Froolem solving ASSESSMENT: 4.-“Togm corms very upegt md nervous. when hove to do sometura out ef the order, 1 feel very ond reyy wear and unset’ B-“T ‘think my life isa disaster, 1 can't have a noce snd productive pergon in my iife, 1 think ine ts not doing peeod thangs “T'm feeling woery every day a grade oF fom foto 10, scare tat something bad could happened and also dustrate every day 24/7" MSE; (General Evelya locks worry , with a gad affect mood ok, tpengarazed. poor inayght poor judem ent® DIAGNOSIS Qencraliae Anwuety disorder (F-41105 Tadtervention During the seaman, the therapist was actively listen her talkong shout the dee situation, was validated because ahe bas been dealing wel the aituation wey well Ciusiig the wesgion ste ia desenbing the rerace. of hav fear and many timer they are veal beewuae she hog alrendy gone through peony sstuatiors that hove led Iver to be amd thiunic Tiles thet. Tt was opented that when those thoughts of fear come to you mind changes st fier dittercat and poditive as everything will be fine and ail thoge investigation is for a reason". Rexpotecfeedbach Evelyn was very atientive and was quiet and relames Progress Note Dated March 10, 2020. R. 922. MOOD CHECKING From one teteni feel 6. thave a bad pein in oy koee COPING CARY Nie BRIDGING: We were talking about my healih stuatoon anal i was tery nervous because i received papers from the social security office " REVIEW OF HOMEWORK (WHAT DI VOU LEARN): J am tying to de whet i have in do but some tomes ts lo herd" Agenda The therapist will help Evelyn to implement copnahve restructuring, ASSESSATENT: A-T am trying to do the best t cam teat sometimes ts very dliffscult , this day teanteven walk well my knee i very bad." B-] think if Like this 1 will need s wheel char" C-] fee] bad, enymg every single day fee the somethmg , i need help-even to inle 5 both” MSIE; (General Quring the session 2velyn was quict alert and cooperative poor wuaght and judgment DIAGNOSIS Generalize Ansty disorder ( F-21,15 Intervention Dunng toe sesmom, the thesapist was actively lstenzg her talicng aout the results, was validated because she has been dealing wiih the very well Duciny the session ghe os deseribing the rewson of her fears and many Goes they ace peal becuase she hos already pone through aituatiory that have led her to be acd thank like that It wea eciented that when thos: thewghte of fear conte te yorur mund changes i for another different. anc poortive ae that whe will eee the octhopedic this afteoveon and will send her fog the MET and will get a eatnvent as soon as poable. Resporseilcedback Evelyn was very attentive and was quiet and relaxes — 21 — Progress Note Dated March 23, 2020. R. 924. MOOD CHECKING From one feel 6. □□□ very neneous with Gus situshon of the Corona Virus COPING CARD? Nis BRIDGING: Tre las sexon we were biking boul my negative Dough: REVIEW OF HOMEWORK (WHAT IND YOU LEARN): J heen doing a be of things te fave coy thimgs well Sut with this stuiion , at this itis isrposaiale " Agenda Thos day spoke wath Evelyn Rolon larch 74, 2020 fom 12:15 11S PM through a phone call 215-917-1124 She gave us a wera consent io pooridle the therapy seston through Ube phone. We will be woeking with her Goughbs replacement: negative for positives mrubor! thoaght ASSESSA0E □□□ A- 0 been wothoa Lot of stress with thes famous winus 1 dent know what to think amd bow to act, tereally scary“ BT] think ts will be i think i twill be socething wen bad "C-T feel very sad, very worry don't iemew whatto do , iam afraid of this sthanion MSE; General Druring the ateaion she was recestive and talkative out worry DIAGNOSIS (F-331) Majer depressive disorder, meurrert, moderate Intervention During the seamen Geot of all was expliomed the dynaenie of tee session . Evelyn was acuve listen by us and was vulidaeed becouse Lhe at this content is dor be woery but doing what we need todo te be safe everytheys will be fine . The last week she had a appointment for the see pains, they fine thet she have othe and tiene ia mething to cure Ulat , juet-take pain medication , but a4 least waa net anything worst , wos eomuraged in those drys af quarantine to dis socaething that we doen't usually do like ip vead , Practice maditstion . tule with eld fiends , we need io doing whatwe have to do te be safe. Evelyn will have paychianie appoutioaent the 28th was encouraged to keep attemd oo the phowe because maybe will be by the phowe or they will seed the prescription to the pharcacy. Respenai feedback Curing the seriion soe was talkanre and cooperatiye Progress Note Dated March 30, 2020. R. 926. MOOD CHECKING From ome tofen. feel maybe). i ara very amicus with dus siteation, COPING CARI Nis BRIDGING: “The last seaion we were talking abow! my irratvomals Chouhis 1am away be ike that speccilly for thos situauen , evesyoody is scare .” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): to dio whint vee satd but ts tom farul, bul a [other bet" Agenala Thas day i spoke wath Brelyn Rioton béareh 30, 2020 fom 2:0) PA bo Do PR througli & phone eal] 5-91 7-1134 She weve wa wera consent to prowbde the therepy session through the phone. We will be woekng with her thoughts replacement, negative for postives wrabocel thoapht We will be weeking educalion and orertation about what she could do in thos situation . ASSESSMENT: am tying todo the best t cam, but the situation is ot easy . thir day 1 have paycliatve appointment and t dowt ever know if they will call me." B-] think this sitastion isseary ,ithaik if i cantpay they will sead me wo cout " C-T feel bed, sed, very amcings i don't knew what well happen, last night i had raped heard brs luke : howe a paroc albeck © MSE; Curing the session she was recepive end talkative out worry DIAGNOSIS (F-331) Major depremive disorder, recurrent, mederae Titervertion During tie phone aceon Evel wad active listen aout her worries, was Validated bevause the sitiaben is not casey , about hes worry the pepchiatrie appointment was give the reat thatthe peyehisinic will call ker in one he or lees, ie hae to be patent becuaee ve not ihe onky oe , About the econpesica] worries , was gaves the infowmation about daffesent peogracas that the governments have to helps those peoples for this can't pay the mortgage ard the others bills . dhe seid thatebe will call thes day. With Socratic questions was explocing what she has been doing these cays and the expenence about this situation , Wis emoouwnged to change those negative tiougits for a positive once and see this poaidemic Testlient form With a clear intention: Gay io yoursele. Tim going io get through this well aad with a learning and with high emotion with love, mulitade, and faith . Angel was encounged to practice the relaxation exercise once a diy aa wel) iny w decrease Loe doeage of infeemation do things at Tome , organize and clean and listen te music Responsetvedback Evelyn was quest and coopersiive aod was ceinforced posinie and was encouraged to cocina doang wheas she is doing 926 — 22 — Progress Note Dated April 13, 2020. R. 932. MOOD CHECKING From one totem. i feel 6 COPING CARD Na BRIDGING: “The last sersion we were talking about my inratiemels thoughts " REVIEW OF HOMEWORK (WHAT DIM VOU LEARN: to iio what we sand but ts too bard, Gut a [other bet * Agenala This day i spoke with Rvelyn Rioton Apedl 13, 200% from 12200 PAC io 1K) PM thoowgh a phone cal] 275-917-1154 She gave usa verbal consent to provide the therapy session through tee phone. We wll be weeleng, wath her thoughts replacement negative bor positives wralsonal thoaght and cont of the mepalive attitude. ASSESSMENT: A-“T am doing beter my heath is better and Tam sleeping better, the worst thing is eny kiee, the sight one is swollen " B-" [ thew the meuation i toc hard and marbe will net going to be shle to work amy maoge ~-" Tim feeling anxicas two times a day every day, depress and last nigit Lequldn't sleep at all.” MSE: (General Dring the session sie was receptive and talkative but worry DIAGNOSIS iF -351) Major depressive disorder, recument, moderate Tntervention Today patient wae puuded by therapet on expeced about her feelings, hae been Touglt for a tet medical problem and that situation makes her feel hopeless but she waa validated becmipe aide she hoa faith and o good fenily support to hos aotivation to continue. were Working With her postive and neentive shisude because goes i pros and cont in hig emotion We were woking with her the an portance of behavior achvstion, , was the mapectimee of wake up carly amd de some exercise. even thou now ale has to be at ome alee can docxereise Responiitecdback Evel was very ationtive and was quoct and rela: Treatment Plan Dated April 20, 2020. R. 934, 938. MOOD CHECKING From one jen. feel 6 COPING CARD? Nis BROMGING: last session we were talking about my inratientls thoughts * REVIEW OF HOMEWORKE (WHAT DID YOU LEARN “T toy to der hat we sand but ts tow bard, but a lstter bet Agenala Thas diy i spoke with Brelyn Riotom Apel 13, 2000 from 12200 Pio 10 PC though « phone cal] 215-91 7-1S¢ She gave usa verbal] consent to provide the therapy session throug the phone. . We wll Se working, with her thoughts replacement, negative bor posiives wrabore! thoaght pros and cont of che megalive attitude. ASSESSMENT: A-"T am doing beter my health is better and Lam sleeping better, the worst thing if my beac. the right ome is swollen " B-" [ think the os ton hard and mavbe will not going tobe sole to work any tacge " Tm feeling ancious two times a day every day, depress and last migit icouldn't sleep at all.” MSE; ‘General Cruing the session sie was receptive and talkative but worry DIAGNOSIS (F-351) Major depressive disorder, current, moderate Latervention Today patient wae pusded by therageat on expeced about her feelings, hae beer Tough for a lot of medical problem andl that situation makes her feel hopeless but she was validated becowee aide she hoa fata o good faenily eupport te has metivsbion bo conte. WeDe Working WIL her postive and nective stiutude because gees in pees and cont im hes emotics: We were woeking swith, her the sn portance of behavior gchivstion , was exploited the anportance of wake up carly and do some exercise. ever thou mow alee has to be at ome thee can do exercise Respenseifecdbuck Evelyn was wory ationtive and was quoet and relases Psychiatric Progress Note Dated April 30, 2020. R. 944. CHIEF COMPLAINTS Current situation‘trigger or concen, Current negative thoughis, Current feelings. Current behavier with intensity Feeqyue HISTORY OF PRESENT ILLNESS (4 clements of the aign and eynplome: aeverity, timing, quality, duration, contest, modifying lattars, chrenic conditions, Review of system (2 elements from thea: constitutions, paychbtric, ocurelegical, consthtutional, musculoskeletal) Past, social, needical history (1 of 3) Telehealt: Med Check via SCM Pabent gave consent louse Telelealih Things under congo) Meds helping w Howewer, her slecp meds heve siopped wocking as well. Siceping bess hors at night Cme of her clients, she used to clean for, died Sad me hard. Back poin wader contol, But inces bust and get swollen. Fans ice on then. March 2020. 47 yo Hsp F, being seen for depression and Pt coping many stessors COVID, stay at hone eeder Pain in beck and other poms, but afraid te go to doe aypts due tecirus, Pt had & som, who shot self 9 years age, when he wee pust 20 years old. This a always in her mind Pt dealing w fianciah stress. She hurt her hack and cana longer work, Pt says sie ts alveays snd and ares, bat mecieatons are helping partally Pt has 2 other children thee moar Deceased son lett Pt agrimdion, also named Whchael NROA HTN, Hemsted Disc, Sciatica Not pregnant Denes DA March 0. Cont Pronac 20 mpg gd, Cont Trazodone 50 op HS, Cont Buspar to 10 mg TH for amoety. Henedits, risks descussed wrth patient. Regular peychotherapy. Pein see PCP for med PL aware of cloeeet CRC, ER, er tocall 910 for eras. Phactnacy 214254500 called by me, eft VAC fer peeseription abore 4 1 refill — 23 — Progress Note Dated May 4, 2020. R. 946. CHECKING From one totem i feel a COPING © ARI? BRIDGING: in the let aesgion we were taking about the seas at hme and the innporianes te be core active REVIEW OF HOMEWORE (WHAT DID YOU LEARN: "lisp to dle what we but is too bard, Gut a litter bit" Agenda Soe wants bo talk woul the stiness dials im having because i wie denied again dee SSD am veorry becawer 1 don't keow whatto de ASSESSMENT: A-"Evelyn came to the center today for thersoy session, se looics sad and with low energy, i wae denied the SS] again and i dont knew what todo" B- Ewelyn had reported m Intest session her healt and her finencial problems, she said thet these are the mainh reason for her to feel depressed. Siometumes tam very warry every dey, sometames ] heave poy self-control omy anges, frustrate . Byelyn reported that she is having between 4 and. § hours of sleep every night MSE: General Bvelyn sppear worry . sad affect, amcioas ,compersive , oviented (63 . goed insigitt and judgrem DIAGNOSIS (F-331) Maye depressive disorder, recurrent, moderate Intervention Following the apenda we continue the paycho-edves tion alb was talking about eae understood and wae making o quesiona were exploring what is happening aed whot why she fey been feeling dee that , she heels frustrate becouse was denied the 33] agam and. it not esey abe has struggling with the financial situation and my tee kids amd my brother who is lag in house do pet understand that swes moeuaged to work with prooles solving strategies , die already define the problem following develop multiple sotutions . inthis case they has to kneeving . aceepting and adjusting dilference . In role play she wees Sowing ws the way that she tlk with the family, wes encouraged tp change some thongs. She was also esssted on use alterneeve thoughts to Grd a solution bor er finaneaal stheion Was asked for the paychdatrie appoimtment and said that she called her and was changed the sleep medication and she will see her m4 weeks Response feedback During the session soe was quick aud cooperative 946 Progress Note Dated May 11, 2020. R. 948. MOOD CHECKING From one toien . feel Gi not feeling well COPING CARD? BROEDGING: “The last acagion we were talking about my araivornals thouglite i ast alwaya be lice that." REVIEW OF HOMEWORK (WILAT DID YOU LEARN: tey to de whet we seed butis hard, i amt practicing Sie relaxation exercise specially atsleeo time and cts helps , but a litter bot" Agenda Thas day we woll be working postive thinking exercises Ewelyn wants to tuk how to entity and avoid real stress ASSESSMENT: A- 1 been doing a botaf tungs, at leas: this weekend, yesterday was mother day and my daughter came over with ory grand-kids , it was mice "8-7 Sunk twill oot geang to be the same because my heakh is metwell " C-] feel better , at hewst less depressive . bus sometanes | feel very and adrasd 2 don't kerorey wehy” MSE: General Evelyn appear worry . sad affect, amecings , cooperative . oriented $3 _ goed inmigitt and judgmen DIAGMOSIS (F-391) Mayor denremive disorder, recurrent, modersic Tntervortion During the seamon, the theme wee ochively listemnag Evel, wes validated her emotions Secnuse ale in doing everything to more we need to start to lem how te RASrTEge the stress because inseme point is god, first of all was encournee oo deverthe the sources of streay, she desenibe 3 mayor of stress and them fas wo desertbe the symptoms when ale expericmot the stieae and them: whatale do to feels better. she could identify sonvething that she has been doing wroog and be changed foc another one more positive Regpense feedback Evelyn war very attentive aad wae quoet ard relaney, — 24 — Progress Note Dated May 18, 2020. R. 950. MOOD CHECKING From one toten.: feel 6. so Raving 2 lot of pain in mv knee COPING CARI? Ne BRIDGING: "The last aeagion we were talling abqaui my iretvonals thowiglete iat always bse lke that." REVIEW OF TOMEWORKE (WHLAT DM YOU LEARN: tey te de what we said butis too herd , i amt practicing Ge relaxation exercise specially at sleep time amd cts helps. but a litter bat” Agenda We will be working thought restructuring with the 30's techoique Validaten of her feelings ASSESSMENT: A- 0 am trying te be beter but.eay health continue at the same my knee is hurting a lot and ow my other ome es hurting too" BT think thatl am going to be Juve thet for ewer "(2-7 feel bad, sad , frustrate .TEDy BONLOUS Sometimes in pantie and that is tween three tines a din * MSE: Ganeral Evelyn agpear werry aad affect, ancioeas conserve oriented 63. pood insight and judgement DIAGNOSIS (F-331) Major deprerive disorder, recurrent, moderate Intervention During the scamon she was active haten when she was desevibong fer fockage , dhe is not feeling well but was walulaied because if she eee foeword phe 18 hewing good improvement, she hae been dong a lot of positive things, baat hes bo ecotimer working with this simesion now , this day well he working with the 3 C's technaque , evaluate the emicteen before the thoagh and them check if that exothw that generate the thaaght and if & is beneficial or useful for her amd her eahh end them change itor another one more poattive, she having diode segative thoughts tut that isrot positive for her her liealth She has te thik that her brother will be better anal she ie doing everything w de ina better condition Response feedback Druring the sevaion sae was very attentive atthe end she wee quieter ard more relax Progress Note Dated May 26, 2020. R. 952. MOOD CHECKING From one tote feel 7.1 been abonng better COPING CARD? Ne BRIDGING: “The last aeagion we were talling about my wraivonala thoaglete i ame alway bee lee that ." REVIEW OF HOMEWORE (WHAT DD YOU LEARN: "toy te de whet vee sand but is tee hace, but helps a litter bit" Agenda] weld Tike wo talkt how T will be dealing wil dais station becmuse mow lam wery negalne ™ ASSESSATENT: A-"T am doing beter cy health js better, but just litter and lam sleeping better, thes weekend i hod my grand-kids at hooe: . i fee so hapoy with thera” B-" ] thank will be geend if startto work ut wtthe seme time ] thiak that 2 could’t det" C-" Pom feeling less anegeus two times aday ewery day, bevs depress” MSE; Evelyn sepear worry , sad affect, aneiows cooperative , oriented $3 , goed insight and judgment DIAGNOSIS (F-331) Major depressive disorder, necurrent, mederae Tatervertion During the scamot, the therapist wae achwely listen, was caccuraged to change those negative thougata fora positive cues, Wad shout her health progiema Sut ie not anything That bad, wor explained how her decugits aftees hex feelings and dee way that-you gee alee Life Responswifeedback Evelyn war litters bt frusicate atthe frat but late on wae different, very atentive andl wae quot ard celames — 25 — Progress Note Dated June 03, 2020. R. 954. MOOD CHECKING From one totem i feel 6. tara sad. nervous and areciows for ihe protests ig meary COPING CARD No BRIDGING: in the ast season we were taking about the steeas at lome and □□□ inaporianee tm be cone active REVIEW OF TOMEWORK (WILAT DD YOU LEARN tsy te delat ve Sacd but is boo had, i amt practicing Se telealion exercise at sleep te amd cts helps . but a Litter bat” T want to congmue talk about how T have to continue dealing with te situation" ASSESSMENT: A-“T been doang better, but Tama niecwrell , the migraine es hitting re so bad) but that itis fora few devs from today “ B-“T think I am ewery day worst, my daughtes is at bone because my grand kids are im panes." C-"T am feeling every single day wery nervous . soruetomes anger frustrate bee oc three mes a day" MSE: ‘General Evelyn appear worry sad affect, anciogs .coopersive , oriented M3. good insight and judgment DIAGNOSIS (F-331) Major depressive disorder, recurrent, moderne Intervention Clinscian weed this interyeniven te analyzes wal Evelyn abonn ihe imporience of beng the most positive thet she con aed thea automate negative Thoughts that con cakes her seal and worry and continues to wait until this sttutions ends alesis tring to see that every neganve attuation hea a solutieo and that she hes tecorinues being motivated Was validated because she is agoodmom and a good grandmother because alwaye she gives a good support to then and that is good. Was encounged to talk with deem to let them koow that dis is temporal ane this aleo will yeas iid wall have to tile the Dest payt inf this stbaaton Response feedback Evelyn way very attentive and was quiet and relames Progress Note Dated June 09, 2020. R. 1004. MOOD CHECKING From one to ten, 1 feel 7, this week tam quieter COPING CARD? No BRIDGING: The last session we were talking ebout my anxiety and stress " REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “Ttry to do what we sad bur is too hard, but a liter bit" Agenda In this session we will be working though restructuring and low to start our new normal life agam ." ASSESSMENT: A-] am trying to do well bul every tome thati think thati have to go out or start again am scare..since last week 1 have my daughter with her family because my granddaughters were seare T think this sttuation will takes lomg, we will gomg to live with this the rest of the Ife. * CI feel sad, very worry . some tunes i don’t even want to go out, 1 slay In myroom." MSE: General Evelyn appear werry , sad atiect, amudous , cooperative oriented 43 , good insight and judgment DIAGNOSIS (7-331) Major depressive disorder, recurrent, moderate Intervention In this session we were talxing about her worries , letin her to know that fear and worry itis normal because there are a lot of death on the world for the same and we have a lot of tame in our house but the life hes to continue and we need to have our life beck , we have to follow the instructions and start to go out Litter by litter , not in crowd places and just for a short periods of time and litter by litter will get the trust back to do what we was doing before but now with seeing the life and what we have aa different way . Response/feedback During the session she was a litter bit anxious at the first but late on was more conscious about it Evelyn was velidated because she has been doing well. Progress Note Dated June 16, 2020. R. 1006. CHECKING From one to ten, i feel 7 i feel 6, the situation is getting better’ COPING CARD? No BRIDGING: in the last session we were talking about my progress and how to keep my self focus in what. want” REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘Ttry to do what we sud but hard, iam tying to be more active but last might" Agenda] have a lot of things done Suri doen't know why am too dewn ° ASSESSMENT: A-1 been doing everything but : don't know 1 feel like this .1 am helping my daughter, she is at hore but now i broke a pipe in the basement " H-7 think that everything ts agamstme " C- 1 feel bad, sad ansious most of the tome , seare that something could happen® MSE: General Evelyn appear worry . sad affect, amuous , cooperative , oriented X3 . good imsight 2nd judgment DIAGNOSIS F-331} Major depressive disorder, recurrent, moderate Intervention During the session, the therapist was actively listening to thew fears, discarding whether they are real or not, she realizes thet sometimes they are mot real, but that they retain in hey mind. Wes instructed that wher fear Hits your mind, turn it around. Instead of thinking of something bad that may happen, think of something positive, Evelyn was encouraged to emjoy the stage that she has been, things happen, when is not one thing ts other and at least her daughter and family are with her and it is enpoying her granddaughters , Her daughter and her son promised to her thet for her birthday will by a ticket to go to Puerto Reco at least for two weeks , and will be for July. God first , if everything come out better. Response/feedback During the session she was at the first, very anxious but at the end was quieter. Progress Note Dated June 23, 2020. R. 1008. MOOD CHECKING "From one to ten. 1 feel 6, the s:tustion is at the same,” COPING CARD? No BRIDGING: don't really semember but: am very nervous i knew that has to be about the situation that we are living. REVIEW OF HOMEWORK (WHAT DID YOU LEARN) "Ttry to do what we sad but is too hard, 1am practicing the relaxation exercise specially at sleep time ated its helps . but a litter bit" Agenda This day t warit to talk about my psychiatric apporittient , my appointment was the 17th but no one calle. This day i would like to talk about About irrational thoughts Validation of hes feelings [ went to talk about my fears ASSESSMENT: A- Tins weekend : was so sad, ‘ust lav bed my datgehter weit back to her House buts am ot well’ B- □ think that: can't even will do thought , 1 want to start to work" C-[ fee sad, cryimg a Jot, more than two times a day ,1 am even sleeping well" MSE: General Evelyn appear worry , sad affect, anxious , cooperative , oriented X3 , good insight and judgement DIAGNOSIS ( F-331) Major depressive disorder, recurrent, moderate Intervention During the session, the therapist was actively listening to ther fears, about everything, was encouraged for these days prepare activities for the family , they could spend time together just the family. ty tospend the most time together without exgumentation. she has to work her negative thought, was instructed te think in positrve because as more negative thoughts is worse .every time a megetive thinking Art her mind think something About the psychiatric appointment was explamed that was explamed that was reschedule for the 25th at IT Response/feedback Evelyn was active. cooperative and talkative . was strongly reinforced Progress Note Dated June 25, 2020. R. 1010. CHIEF COMPLAINTS Current situation/trigger or comcern, Current negative theughts, Current feelings, Current behavior with imtensity and frequency. HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 elements from these: constitutional, psychiatric, neurological, constitutional, musculoskeletal) Past, family, social, medical history (1 of 3) Feeling calmer, sleeping better. Denies oversedation. Meds helping. Mo sue effect. One of ber clients, she wed to clean for, died. Stall has 5 other clients, Back pam under contre! Hut knecs hurt and get swollen. Puts ice on them, Cant work a3 much as she wants to. Wants to pay bills. Maren 2020: 47 yo Hisp F, being seen for depression ard anxiety. Pt coping w many stressors. COVID, stay at home order. Fain in back ad other joints, but afraid to go to doe appts due to virus. Pr had ason, who shot self 9 years ago, when he was must 20-years old. This is always inher mind. Pt dealing w financials stress. She hurt her back and cas ne longer work. Pt sayy she is always sad and anxous, but medications are helping partially, Pt has 2 other children in ther 20's now, Deceased son left Pt 9 grandson, also mamed Michael NEDA HTN, Hemisted Disc, Sciatica Not pregnant Denies D&A March 2020. Cont Prozac 20 mg qd, Cont Trazodone 50 mg HS, Cont Buspar to 10mg TID for anxiety. Benefits, riske discussed with patient. Regular psychotherapy. Ptto see PCP for med issues. Praware of closest CRC, ER, or to eall 911 for cxsis. Pharmacy 7454754500 called by me, left VMI for preseription above Progress Note Dated July 21, 2020. R. 1012. MOOD CHECKING From one ten, 1 feel 4 COPING CARD? No BRIDGING: “The last session we were talcing about my itrationals thoughts i am away be like that." REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: ‘Ttey to do what we said but is too herd , but a litter bit" Agenda Evelyn wants talk about how she can continue dealing with this stualion” ASSESSMENT: A- “Tam continue very upset with my boy Giend, we broke up because he is jealous and he gets mad because i went bo Puerto Race. " B- think my life is 2 disaster , ean’t have a mee person m my Ife, 1 think he ts not doing good things * C- “I"m feeling worry every day , anxious, a grade of 5 from | to 10, scare that something bad could happened and also frustrate every day 24/7" MISE: General Evelyn appear worry , sad affect, anxious , cooperative oriented , good insight and judemem DIAGNOSIS ( F-331)} Major depressive disorder, recurrent, moderate Intervention During the session, the therapist was actively stenting her talking about the situstion, she has to think what she want for her life was encoutaged to open the communication with her boytriend and esoress herself | define her feelings and decide what they will going to do with that relationstp . Evelyn was validated her feelings because she do what she has to do , was asked about her trip , said that she had a nice time there with her sisters .. Response/feedback Evelyn was very attentive end was quiet and relaxes. Progress Note Dated July 29, 2020. R. 1014. MOOD CHECKING From one to ten, 1 feel & the situation ts the same. COPING CARD! No BRIDGING: “The last session we were talking about my itrationals thoughts iam always like that." REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “Ttry to do what we said but is too hard, iam prackciug the relaxation exercise specially at sleep time ard ite helps but ust sometimes” Agenda "T would like to talk how I wall be dealing with this situation because now I am very negative “ ASSESSMENT: A- “lam doing better but my health is net well, fT continue with ths pain m my leg and my back" B-"T think this will be a failure, think thet [ am going erazy, I think that have something bad and the doctors doesn’t want to tell me nothing” C-" Tm feeling very ansuous two or three tives a day every day, very depress and crying for no reason two or three times a day MSE: General Evelyn appear worry , sad affect, anxious , cooperative , oriented K3 , good insight and judement DIAGNOSIS (296.25) 53. |} Major depressive Disorder, Recuctent epriodes Intervention During the session, the therepist was actively listening her talking ebout the situation, she could identify some irmtional thoughts as “Always | have to be m pain “was explainmg her health problem and has reasons for her hopeless feeling but was encouraged to change that thought for another one 2s “1 have this problem but 1s net something that I will died for it because I am dealing with for a long ome” Responsefeedback Evelyn was liter bit frustrate at the first but late on was different, very attentive and was quiet and relaxes. Progress Note Dated July 30, 2020. R. 841. Chief Complaint tems History of Present [ilivess □ 47 yo Haap F, being acer for deprecation and amocty. Not working. Tene. Thinking too crouch. Meds leiping, Mo aide effect. Stall has 5 othe elena. Hack . need hurt and get swollen. Puts doe on thee, Cant work ever ev she warts to, Waorta to pay bills. March 2000: Bt W mun stressors, COVID, stay at home order Puin im back and other poms, but afraid op ge to doc apts due to virus. FA hed! 2 son, whe shot years when he was just 20 years old. This ws always in her mind Ft dealing w financials stress. She burt her back und can noe longer work. Pt says slie is always sad.ond acpcous, but medications are helping partially. Pt has 2other childben in tren 2's now, Deceased son left Pt a grandson, 12 yn, also named Micheel NEDA ATM, Hemiabed Disc, Scistice Met pregnant Denies Dit Son, sister help w bills Lives 22 yo son Tt yo daughter lives close by. 3 granddaughters Worrying, cant enpyy thimgs. lnaptient Peych Denies Suncide Attempt Denies Die’ Denies Legal Desies MSE awake, coOpeMlre, engimang speech narmoprodluctive, m2 vol, ol tone mood amicus TP logical, goal directed TS no avh, no sah, good magi and judgement ooented «3 B-P-3 Formulation 47 yo Aisp F compliant dealing w cuultple medical issues, also cheonie pain, Likes ip work. Work uratable. Stress w iinances. Alwates thinking af deceased son Relves well w remaimine childenand arandchikten Denes help. Mo Dub Progress Note Dated August 05, 2020. R. 1016. MOOD CHECKING From one toten, 1 feel □□ i been so sad these days. COPING CARD? Mo BRIDGING: We were talking about the situation that we are living REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘Ttey to do what we said but hard, but a liter bit, thaa weekend: was with omy branddaughters with my daughter and prandchildren" Agenda I would like to talk how I will be dealing with tis situation because now lam very negative “ This day we will be working with the tx plan fer the next 120 days ASSESSMENT: A- “Lan act well, my health is not well, had a cortisone impection but the gain still there. “ B-"T think this will be so bad if7 continue like that I will need @ surgery but will be worst.” C-"['m feeling very amious (yo of three tines 3 day every day , very deoress and come for no reason two or three times a day. MSE: General Evelyn appear worry . sad affect, armuous , cooperative , oriented 3, good insight and judgrment DIAGNOSIS (296.277 33,1) Major depressive Disorder, Recwrent episodes Intervention During the session, the therapist was actively listening to Evelyn, she was validated because she has been doing well, she appreciate all the information that I gave her the other day, she already applied for unemployment and received and information that they will send her the retroactive for all the tame that they should send her and in welfare they increase the foods stamps . Was encowaged to increase those negative thoughts for a posilive once, we started to work with her problem Response/feedback Evelyn was very attentive end was quiet and relaxes Treatment/Recovery Plan Dated August 5, 2020. R. 1018, 1020. Diagnosis ( please add the DX) (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes (Indicate Specitic Stressors) Her medical and economical issues Client's Strengths (Use the one in the Recovery Goal): Motivation to continue her treatment , good family support syster Challenge to Treatment: Improve her medical issues . be more positive Anticipated Length of Treatment: 3-6 Months For Update Only: (Review of Progress since Last Plan) Update Describe progress During the last 120 dave Evelyn shows mild progress , her health is more stable buti am not working . CONCERNS -1(What client states problem is, activating event, beliefs, emotions, behavior, relational problems, and somatization) A- “T am not well, ny health is not well, Thad a cortisone injection but the pain still there. “BT think this will he so bad if | continue like that [will need a surgery but will be werst’* C-" Im feehng very anxious two or three times a day every day. very depress and crving for no reason bwo or three times a day. Long Term Goal / Discharge Criteria (What will be accomplished by the client at end of treatment) Evelyn will alleviate depressed mood and obiain an adequate level of functioning in. the daily living Short-term Goal: (What will be done over the next 4 months to achieve long term goal.) | Decrease the level of the BDI-I (From 30- moderate dep to 25= Moderate Depression) 2- Decrease the frequency of cprodes of sadness al least once a week. Modality including medicalion management & Responsible person The therapist will be working with Evelyn individual therapy and psychiatric for medication check up, Responsible person: the therapist , psychiatric and patient, Interventions [he therapist will continue working with CBT. To implement cognitive restructuring Continue with psycho education .The therapist psycho educated about the imporlance the being consistent with her treatment The therapist and Evelyn will work on improving her coping skills to decrease her feeling of anxiety The therapist will be utilizing validation We will be working with the 3 C's techniques will be practicing meditation, mindfulness to reduce her anxious level RECOVERY GOAL/PERSONAL VISION/WHAT I WANT TO ACHIEVE [ness tnanagement Family involvement What do [ want to work now/vhat skills I need, how I can use my support system and resources from my community “Improve my emotions my stress and T am always worry for the most simple thing” How | am going to get there/How my strengths can help me to get there (include cultural values and spiritual beliefs and support system) I Need to continue assisting to the therapy sessions . following the instructions of the drs . taking my medications IN CASE OF CRISIS In case of crisis 1 20 to my room, i just want to be glone FACTORS THAT HAVE CONTRIBUTED TO AN INCREASED IN SYMPTOMS When the health problems gets worst and the economical INDICATOR & OF WHEN SYMPTOMS BEGIN TO WORSEN I can't stop cry think too much STRATEGIES THAT CAN BE UTILIZED WHEN EXPERIENCING WARNING SINGS {indicate specific intervention) Watch tv , dav alone. Progress Note Dated August 12, 2020. R. 1022. MOOD CHECKING From one to ten, 1 feel 6, the sttustion ts at the same COPING CARD? No BRIDGING: fn the last sess:on we were talking about the stress that we are living and my health problems. REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: To be honest .i didn't did nothing Agenda I would like to talk hew ] willbe dealme with this sttwation because now Tam very negative “ ASSESSMENT: “Tam doing better but my health is net well, continue with @ lot of pain inp and leg” B-“T think this will be a failure, I think thet T am gomg crazy, I think that I have something bad and the doctors doesn’t want to tell me nothing” C-" I'm feeling less aimcious fyo times 3 day every day, less depress” MSE: General Evelyn agpear worry , sad affect, amsious , cooperative , oriented 43 , good insight and judgment DIAGNOSIS (296.257 33.1) Major depressive Disorder, Recurrent episodes Intervention During the session, the therapist was actively listening, was encouraged to increase those negative thoughts for a positive once, was talkeng shout her health prodierns Gut is not anything That bed, was explamed hw we wall gn to be working to control her panics. Byelyn has been very dewn because 1 culled to a lawyer office tea number thet was geve her and he did not sevept the case , said that she has to weit ull she tum at least 52 years old and that is not posmble because i can't really work. . Response‘feedback Byelyn was very attentive and wes gine and relaxes Progress Note Dated August 18, 2020. R. 1024. MOOD CHECKING From one to ten, : feel 61 had dr appomtment COPING CARD? No BRIDHGING: in the last session we were talking about the stress that i have family. REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘Ttry to do what we sad but is too hard, because the sittation ts mot for easy* Agenda We will be working thought restructuring with the 3 C's technique Validation of her feelin ASSESSMENT: an tring to do better but my health continue at the same my knee is hurting a lotthis day i weit to see the doctor " B- I think that Iwall not be the same ever. " C-] feel bad , sad, frustrate , very anxious sometimes in pane and that is two or three times a day * MSE: General Evelyn appear worry , sad affect, anmious , cooperative . oriented 43 , good insight and judgement DIAGNOSIS (296.227 33.1) Major depressive Disorder, Recwreat episodes Intervention During the sesnon she was active listen when she was describing her feelings , she is notteeling well but was validated because if she see forward she tshaving good improvement, she has been doing 2 lot of positive things, but has to continue woreing with the sttuation , seid that she went to the dr this day and he said the situation with my lovee is arthritis and he can't too much and the situation in my lip is related with my back , he said thet i have to make an appointment with the surgeon dr because that's the only thing that she could do; this day will be working with the 3 (C's technique , evaluate the emotion before the thought and them check if that emotion that generate the thought and if itis beneficial or useful for her and her health and them change it for another ene more postive, she 1s having those negabve thoughts but that is not positive for her and her health Response/feedback During the session she was very attentive at the end she was quicter and more relax. Progress Note Dated August 25, 2020. R. 1026. MOOD CHECKING From one to ten COPING CARD? Ne BRIDNGING: in the last session we were talking about the stress et home and my health problems . REVIEW OF HOMEWORK (WHAT DID YOU LEARN} ‘Ltcy to do what we saul but 1s too herd , because the situation ts pot for easy” Agenda] would like to talk how 7 wall be dealing with this sttation because now Tam very negative © ASSESSMENT: A- “Tam doing better but my health is mot well, continue with this pain and this cold symptoms J need te go to the emergency room" B- “T think this will be a failure, 1 think that Tam going crazy, I thmk that] have something bad and the doctors doesi't want to tell me nothmg” C-" Tm feehng very angious two or three times a day every day , very depressed and crying for mo reason two or [hive times 2 day” MSE: Evelyn appear wory , sad affect, amuous , cooperative , onented 43, good insight and judgement DIAGNOSIS (296.27! 33,1} Major depressive Disorder, Recurrent episodes Intervention During the session, the therapist was actively Listening her talking shout the situation, she could identify some irrational thoughts as “Always [have to be sick “was explening her health problem and has reasons for her hopeless feeling but was encouresed to change that thought for another one as “T have this problem but is not something that I will dived for it because Lam dealing with for a long tune” Response/feedback Wes |stters bit frustrate at the first but late on was different, very attentive and was quiet and relaxes Psychiatric Progress Note August 27, 2020. R. 1028. CHIEF COMPLAINTS Current situation/trigger or concern, Current negative thoughts. Current feelings, Current behavior with intensity and frequency. HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 clements from these: constitutional, psychiatric, neurological, constitutional, musculoskeletal) Past, family, social, nvedical history (1 of 3) Feeling ok. Sleeping good. No side effects waomeds. Family is doing well. June 2020 Feeling calmer, sleeping better, Denies owersedation. Meds helping. No side effect. One of her clients, she used to clean for, died Still has 5 other chents. Back pain under control. But knees hurt and eet swollen. Puts ice on them. Cant work as much as she wants to. Wants to pey bills. March 2020: 47 yo Hisp F, being seen for depression and anmety. Pt coping w many stressors. COVID, stay at home order. Paia in back and other joints, but afraid to go to dee appts duc to virus. Prhad a son, who shot self 9 ycar ago, wien he wag just 20 years old This is always inher ind. Pt dealing w fivancials stress. She hurt her back and can no longer work Ptsays she is always sad and amaous, but medications are helping partially. Pt has 2 other children thei 2's now Deceased son left Ft a grandson, also named Michael NRDA HTM, Hernated Dise, Sciatica Mot pregnant Denies DRA March 2020. Cont Prozac 20 me qd. Cont Trazodone 50 mg HS, Cont Buspar to 10mg TID for anxiety. Benefits, risks discussed with patient. Regular psychotherapy. Pt to see PCP for med issues. Pt aware of closest CRC, BR, orto call 911 for crisis. Pharmacy 2154254500 called ty me, left VM for prescription above Progress Note Dated September 10, 2020. R. 1030. MOOD CHECKING Frera one te ten, I feel less thansix , ident feel well. COPING CARD? No BRIDGING: In the last session we were talking about the stress at home and my health problems . REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: To be homes: .1 did't did nothing Agenda We wall be working wath thought restructuring , the 3 C's technique ASSESSMENT: A-“T feel better but continue having lot inconventent sumy house , whens not the water , the ight, always is somethimg new “ B- “T alwavs think bad think and I will be very anxious if this don't step " C-“T'm feeling worry every dey , anxious, ¢ grade of 7 from | to 10, scare that something bad could happened and also frustrate * MSE: General Evelyn appear worry . sad affect, anxious , cooperative . oriented X3 , good insight and judgment. DIAGNOSIS (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention During the sesnon she was active listen when she was desertbing her feelmgs , she is not feeling well but was validated because if she see forward she ishaving good improvement , she has been doing a lot of positive things, but has to continue working with this situation now , this day will be working with the 3 C's technique , evaluate the emotion before the thought and them cheek if that emotion that generate the thoupht end if if is beneficial or useful for her and her health end them change it for smother one more positeve, she is hewing those negative thoughts but that not positive for her and her health She has to think that her brother will be better and she 1s doing everything to be an a better condition Response/feedback During the session she was very allentive at the end she was quieter and more relax. Progress Note Dated September 16, 2020. R. 1032. MOOD CHECKING From one te ten, | fee] &. 1 feel the same COPING CARD? Mo BRIDGING: in the last session we were talking about the stress with my health problems . REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “Ttry to do what we sud but is too herd, its helps , but sust a litle bit" would like to cortunue talking about the situation thet am having now Education about the situation of her heelth* ASSESSMENT. A-I am trying to do the beat Sut my health is not well , mow the drs that 1 meed stegery " B- [think if i have the surgery 1 will not be the same again" □□□ fee] worry every single day , crying for the most sumple thing , and lastrmght : was up almost the whole might " MSE: General Evelyn appear worry . sed affect, ammious , cooperative . oriented X3 . good insight and judgment. DIAGNOSIS (296.2¥/ 33.1) Majer depressive Disorder, Recwrent episodes Intervention Therapist worked with Evelyn preeticing active listening and validating her feelings, we start to talk about her fears and her worries becsuse she said that she has been seeing people that they dida’t pood after the surgery and another has been died, was validated because itis rue but alse she has seen a lotof people who has done well and the improvement in the health is huge, was encouraged to keep the appotniment because that's the reason of that appointment. , It is orientation. Evelyn was motivated to continue with the process to sce what is going to be Response/feedback Byelyn was very attentive end was quiet tearful and very angry tn moment Progress Note Dated September 23, 2020. R. 1034. MOOD CHECKING From one totem, i feel 6 COPING CARD? No BRIDGING: “The last session we were talking about my trretionals thoughts i em always like that " REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: "Ttry to do what we said bur is too hard , but a liner bit" Agenda How to Increase Coping Skulls to cope with stressors. We will be working with the 3 C's technique. Mindfulness exercise." ASSESSMENT: A- 1 een doing better but sometumes when: have too much things to dor get mad .because 1 can't because my health" B-T think that lam amoody person and that's why don't have no one with me feel writable , frustrate specially when i makes other feel bad .1 can't ever sicep well" MSE: General Evelyn appear worry , sad affect, areuous , cooperative , oriented KG , good insight and judgement. DIAGNOSIS (296. □□□ 33.1) Mayor depressive Disorder, Recurrent episodes Intervention The therapist active listen Evelyn explaining the what she have and how she feels, she could identify an trrational thought because she think if she contumue I:ke that she will mot going to be able to do nothing , she has to wait for the results and the evaluation . maybe itis something sitiple and she can’t be worrying about it maybe the mew treatment will be betber. Response/feedback Evelyn was very attentive and way quiet tearful and very angry in moment Progress Note Dated September 30, 2020. R. 1036. MOOD CHECKING From one to ten, 1 feel 7, am doing better COPING CARD? No BRIDWGING: In the last session we were talking about the stress at home and ny health problems REVIEW OF HOMEWORK (WHAT DID YOU LEARN, “Ttey to do what we said but is too hard, i am practicing the relaxation exercise specially at sleep tune and its helps . but a litter bet" want to talk about my situation , 1 still out of a job and a litter bit about my brother “ ASSESSMENT: A- "Evelyn is worry because she needs bo find a job and is worry for her brother, he isnot-well , was better but now is not well” B “Tihink he will net gomg to make tf this time, ] don’t see him well” C-" Ti feeling sed three or four times a day worry for my brother every day . and amcious almost two times a day for sround an hour”” MSE: General Evelyn appear worry . sad affect. amuous , cooperative . oriented X3 , good insight and judgment. DIAGNOSIS (296.257 33.1) Major depressive Disorder, Recurrent epusodes Intervention During the session, the therapist was actively listening her talking about the situation of her brother, he had an stroke and after that it is consequences , was validated because she always has been there for him and more and that iss good value of her. About the negative thought, she has to contimue working in that, was encouraged to keep a record of her thoughts , posttrves and negative once in different situations, the negative thoughts usually are not good for the emotions Response/feedback Evelyn was very attentive and was quict and relaxes Psychiatric Progress Notes Dated October 01, 2020. R. 1038. CHIEF COMPLAINTS Current situation/trigger or concern. Current negative thoughts. Current feelings. Current behavior with intensity and frequency, oh 2159171134 Medication Adjustment... doing ok HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 elements from these: constitutional, psychiatric, weurological, constitutional, musculoskeletal) Past, family, social, medical history (1 of 3) 47 yo Hisp F, being seen for depression and anxiety Anniversary of sons death coming up... Back and ankle pain. Ankle swollen Getting water pills Doing ok Some eversedation Sleeping good. No side effects w meds. Family is dome well. Ptcoping many stressors. COVID, stay at home order. back and other joints, out airaid to ao te doc apgts due to virus. Ft had a son, who shot self 9 years ago, when he was ust 20 years old. This is always in ber sind Pt dealing w financials stress. She wt her back and can no longer work. Pr says she ts always sad and anxious, but medications are helping partially. Pt has 2 other children in ther 20's now, Deceased son left ta grandson, also named Michael WEDA ATN, Remtated Disc, Sciatica, Beck Pain. Not pregnant Denies Dic, Progress Note Dated October 06, 2020. R. 1040. MOOD CHECKING From one to ten, 1 feel & | the sttuation is at the same COPING CARD? No BRIDGING: in the last session we were talking about my health problems . REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘Ttey to do what we sad but is too hard , its helps , but just a little bit’ Agenda Kelp Evelyn to identify and discuss methods used to cope with stress ASSESSMENT: A-I been doing my things but sometimes is too hard . i bad to send all the papers for the social securtty again , 1 feel tire of everything " B+] think that1 can't be dealing wrth this for a long te " feel, some tomes frustrate , very anxious , with a sad affect as well , something that t can't contre! MISE: General Evelyn appear worry , sad affect, amuous , coopcrauve , oriented X3 , good insight and judamem. DIAGNOSIS (295, 2F/ 33.1) Major depressive Disorder, Recurrent episodes Intervention We initiate the session with @ mindfulness exercise to help her to be in calm , after thet she was active listening and was validated because everything thet was very confused and is not easy to be up and down thinking one thing and other but wes strongly remforced because the results came out negative at the end that is what she has to take about tt and appreciate that, the drs aloo are humans beans and also they could make mistakes , was encouraged to practice the 3C's technique to evaluate those thoughts before the emotions evaluate and see afit they are beneficial for her emotions and them change st for another once more positive and keeos doing that constantly to keep those negative thougiits out of her mud Response/feedback Evelyn was very attentive and was quict and eooperatire Progress Note Dated October 13, 2020. R. 1042. MOOD CHECKING From one toten, : feel 6 COPING CARD? No BRIDGING: In the last session we were talking about the stress of avy health problems REVIEW OF HOMEWORK (WHAT DID YOU LEARN} “Ttry to do what we sard but is too hard , 1am prachemg the relaxation exercise specially at sleep time and ts helps , but pust a letter bit” Agenda 1 been doing a lot of things to have my things well " ASSESSMENT: A: "Lam feeling less depressed. Still working with my dwaghter but not too much because my health problem *, B: "T believe that 1 can get better al managing my thinking". C:"T still get depressed two or three times a day © MSE: General Evelyn appear worry , sad affect, amucus , cooperative , oriented X3 , good insight and fudemem. DIAGNOSIS (296 2F/ 35.1) Major depressive Disorder, Recurrent episodes Intervention The therapist continued to work with Byvelyn on identifying and containing unhelpful thoughts. Bvelyn was validated she has been doing better ,she is doing some job, thet’s good step for her , was encouraged to see how she startand where she is , she understand and see that but the negative thoughts are been very often. Was encouraged bo increase to The necessary support and encouragement were grven during session. was practice a relaxation exercise with positive thinking exercise Response/feedback Evelyn will coatuie applying the strategies discussed in the therapy session, as think what she meeds and what she wants” Progress Note Dated October 22, 2020. R. 1044. MOOD CHECKING From one , 1 feel 6 very down, yesterday was my pass son birthday COPING CARY Mo BRIDGING: tn the last session we were talking about the stress with ay health problenis . REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘Ttry te de what we sid isto hard, sts helps, but ust a inthe bit" Agenda woubl like to talk how I wall be dealin woth this sttuation because now lam very negative “ ASSESSMENT: “Tam domg better but my healthis oot well, fT continue with this pain end this cold symptoms J meed to go to the emergency room, yesterday was a bad day , it was my pass son birthday andi was bad" B-"T think this will be a failure, I think that I am going crazy, I think sf my son would be alive would be different" C-" I'm feeling very anxious two or three tunes a day every day, very depressed and crying for no reason two or three times a.day “ MSE: General Evelyn has sad affect mood depress, mood at the same , poor insight and judgment DIAGNOSIS (296.28) 33.1) Major depressive Disorder, Recurrent epode Intervention During the session, the therapist was actively listening her talking ebout the situation, she could identify some tretional thoughts as “Always [ have to be sick, of my son would be alive i would be a happier person “was explaining her health problem and hes reasons for her hopeless but was encouraged to change that thought for another one as “I have this problem but1s not something that I will died for it because I am dealing with for along time” about her son, she has to think that things happen and no one can't control tbo: change st aul we have to accept iteven is something that hard and every single day day and year hurl a lot Response/feedback Eyelyn was litters brt frustrate at the first out late on was different, very attentive and was quiet and relaxes Progress Note Dated October 28, 2020. R. 1046. MOOD CHECKING From one ten, 1 feel 6, i was at the hospital COPING CARD? No BRIDGING: In the last session we were talking about my progress with my pains and the importance to be ioe active * REVIEW OF HOMEWORK (WHAT DID YOU LEARN: ‘Ttey to do what we said but is too hard." Agenda would like te talk how te manage this stressful situation because thos situstion is net easy ASSESSMENT: A- I've been toying to do things the best [ cen, but last Saturday] was in a friend's house and J] started to feel like I was short of air and faintng and when I woke up, [ was inthe hospital.* B- 7 think Im from bad to worse, I'm always sick," C-1 feel deeply sad, very worrted, very afraid and very amcous." MSE: General Evelyn has sad affect ,mood depress, mood at the same , poor insight and judgment DIAGNOSIS (296.2F/ 33.1) Major depressive Disorder, Recurrent episode Intervention During the session, the therapist was actively Listening: her telktne about the situation, she could identify some irrational thoughts as “Always [ hove to be sick or my situntion goes from bad to worse “was explaining her health problem and has reesons for her hopeless feelings ris the second time that she felt.at home and has to be scary satd thet she never ever before had what happen the last Saturday, in the emergency room they has te schedule an appointment with her primary dr, was encouraged to change that theught for another ome as“ 1 have this problem but is not something that I wall died for it because ] am dealing with this tors long tune the drs will find a solution * Response/feedback Churing the therapy wes quiet and attenteve, after the session was nore relex Progress Note Dated November 04, 2020. R. 1048. MOOD CHECKING From one to tent feel 6 COPING CARD? No BRIDWGING: in the last session we were talking about the stress thet 1 have with my health condition. REVIEW OF HOMEWORE (WHAT DID YOU LEARN): [try to do what we said but is too herd, 1 am practicing the relaxation exercise specially at sleep time and tts helps , but litter bit" Agenda About how 1 could deal with my situation because sometimes I feel very gad. ASSESSMENT: A-I been worry lately, because health problems out hope to gets better.“ B: [have to see the doctor I don’t know why T think something wrong with me and my health”. C: I feel] sad, very werry most of the tive and sometimes frustrate □ MSE: General Evelyn has sad affect mood depress, mood at the same , poor insight and Judement DIAGNOSIS (295. 33.1) Mayor depressive Disorder, Recurrent episode Trtervention Climcian used this intervention te analyzes with Evelya about the importance of being the most positive that she can and avoid those negative thoughts that cen makes her sed and worry and continues to weit until this sttustions ends always trying to see that every negative has a solution and that she has to contmwes bemg motivated Was validated because she is a good mom anda good grandmother becawe always she gives a good support to them and thatis good. Was encouraged to talk with ther te let them know that this is temporal and this also will pass and will have to take the best part of this sttuation. Response/feedback Evelyn was attentive and quiet, was remforced positrre for it Progress Note Dated November 10, 2020. R. 1050. MOOD CHECKING From one ten, 1 feel 61am tired COPING CARD? No BRIDGING: in the last session we were talking about the stress that 1 have with my health. REVIEW OF HOMEWORK (WHAT DID YOU LEARN “Ttry to do what we satd but is too herd, 1am practicing the relaxation exercise especially at sleep time andits helps , but yust a little bit" Agenda I would like to talk how I will be dealing with this situation because now J am very negative We will be working with the weatment plan for the next 120 days ASSESSMIENT: A- “Lam doing better but my healthis net well, ofl continue with this pain and this cold symptoms. if i continue with this symptoms iwill go te the de" B-"T think this wall be a failure, I think that lam going crazy, this situation is is too much when don't have one thing 1 have other C-"T'm feeling very anxious two or three times a day every day , very depressed and cong for no reason two or three times 2 day MSE: General Evelyn expressed that she had been less sad, less worry , OX3 , good insight and judgment . DIAGNOSIS Major depressive disorder Recurrent ( 796.20) F-33.1) Intervention During the session, the therapist was actovely listening her talking sbout the situation, she could identify some irrational thoughts as I have to be sick “was explaining her health problem and has reasons for her hopeless feeling but was encouraged to change that thought for another one as“ In these season with the weather changes a lot of people has allergies or could, that's scmething sormal inthis season a lot of people has could we were evaluating her progress in the past 120 days , she had mild progress because the seary sifialion with the pandemic and her health condition Response/feedback was litters bit frustrate at the first but late on was different, very attentive and was quiet and relaxes aner Treatment/Recovery Plan Dated November 10, 2020. R. 1054-56. Diagnosis ( please add the DX) (296.2F/ 33.1) Major depressive Disorder. Recurrent episades (Indicate Specitic Stressors) Her medical and economical issues , Lonely feeling Strengths (Use the one in the Recovery Goal}: Good motivation for the treatment Challenge to Treatment: Increase her social activitics Anticipated Length of Treatment: 3-6 Months: For Update Only: (Review of Progress since Last Plan) Initia] treatment plan Describe progress During the last 120 days Evelyn shows mild improvement in the depressed signa and symptoms, she continue taking the medication treatment but the frequency to the therapy and psychiatric sessions it was poor CONCERNS -1(What client states problem is, activating event, beliefs, emotions, behavior, relational problems, and somatization) A- “Tam doing betier but my health is not well, if 1 continue with this pain and this cold symptoms need to go to the emergeney room" B-“4 think this will be a failure, | think that [am going crazy, | think that [ have something bad and the doctors docen’t want to tell me nothing” C- "I'm fecling very anxious two or three times a day every day , very depressed and erying for no reason two or three times a day“ Long Term Goal / Discharge Criteria (What will be accom plished by ihe client at end of treatment) Evelyn will improve her emotional control and will return ta a normal life following the clinician directions . Short-term Goal: (What will be done over the next 4 months to achieve lang term goal.) 1- By the next 120 days Evelyn will develop positive cognitions about her and the future 2- By the next 120: days Evelyn will be seeing the psychiatric to continue with the medications, Modality including medication management & Responsible person [he therapist will be working with Evelyn individual therapy and paychiatric sessions for medication check up, Responsible person: the therapist , psychiatric and patient, Interventions In individual therapy we will l- We wall be working with validation of her feelings. 2 The therapist will assist Evelyn about develops an awareness of her cognitive message that reinforce hopelessness and helplessness. 3- The therapist will educate her about her medical problems. 4- Use real logic to challenge each dysfunctional thought or negative thinking pattern accuracy, replacing it with a posilive, logical thought. will utilize the 3 technique $< Elaborate a plan of different healthy and pleasant activities te develop in the next 4 months (Behavior Actrvation). 4-Work with thoughis replacement, negative for pusilives. RECOVERY GOAL/PERSONAL VISION/WHAT TE WANT TO ACHIEVE management Family involvement What do I want to work now/vhat skills T need, how I can use my support system and resources from my community Improve the family communication and avoid my bad feclings (sad/anxictr) and the scl? isolation" How I am going to get there/Tow my strengths can help me to get there (include cultural values and spiritual beliefs and support system) 1 need improve my communications skills and my level of tolerance and acceptation of my medical problems” IN CASE OF CRISIS In case of crisis i 20 to my room, i just. want Lo be alone, FACTORS THAT HAVE CONTRIBUTED TO AN INCREASED IN SYMPTOMS when my medical problems gels worsl, when i try te do something in my house and i can't INDICATOR § OF WHER SYMPTOMS BEGIN TO WORSEN I can't stay still, ovy heart goes more than a LOO, shaking hands STRATEGIES THAT CAN BE UTILIZED WHEN IFEX PERIENCING WARNING SINGS {indicate specific intervention) Watch tv , stay alone, Progress Note Dated November 23, 2020. R. 1052. MOOD CHECKING From one to ten, : feel 6 COPING CARD? No BRIDGING: In the last sesston we were talking about the stress at home and the importance to be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN® "Ttry to do what we said but is too hard, 1am practicing the relaxation exercise espectally at sleep time and tts helps , but a litter bit" AgendaT would like to talk about, what: will do wath all this papers . Problem solving. ASSESSMENT: A- “lam continue very upset and nervous , when, 1 have to do something out of the order , 1 feel very upset" B- “I think avy Life is a disaster . : think he is not domg good things “ C- “[’m feeling worry every day , anxious, a grade of 5 from | to 10, scare that something bad could happened and also frustrate every day 24/7" MSE: General Evelyn looks worry , with a gad affect mood ok, tp organized, poor insight poor judament’ DIAGNOSIS Major depressive disorder Recurrent (296.20 / F-33.1) Intervention During the session, the therapist was actively listening her talking about the the situation, was validated because she has been dealing with the sttuation. very well During the session she ts describing the reason of her fears and many times they are real because she las already gone through many situations that have led her te be and think like that. It was onented that when those thoughts of fear come to your mind changes st for another diferent and postive as everything will be fine and all those mweskgation is for accason, at this moment is less lonely because her sister is With her till December 12 . for thanksgiving just will be with her sister and dawehter with family" Response/feedback Byelyn was very attentive and was quiet and relaxes: Progress Note Dated December 07, 2020. R. 1058. MOOD CHECKING From one to ten, 1 feel 6 COPING CARD? No BRIDGING: in the last session we were talking about the stress thet 1 have wath my health. REVIEW OF HOMEWORK (WHAT DID YOU LEARN} “Ltry to do what we said but is too hard, its helps, but ust a little bit" Agenda We will be working thought restructuring with the 3 C's technique Valudation of her feelings ASSESSMENT: A-1] am trying to be better but my health continue at the same i been anxious, 1 had psychyatric sppomtment but 1 wes waiting for her call" think that I am not going to be like that for ever " C-1 feel bad , sad, frustrate , very areaous sometimes mm pante and that is two or three limes a day © MSE: General Evelyn looks worry , with asad affect mood ok, tp orgamzed, poor insight poor judgment’ DIAGNOSIS Majer depressive diserder Recurrent (296.20! F-33173 Intervention During the session she was active listen when she was describing her feelings , she is not feeling well but was validated because if she see forward she is having good improvement, she has been doing 2 lot of positive things, but has to contimme working with this sttueion now’ , this day will be werking with the 3 C's technique , evaluate the emotion before the thought and them check. if that emotion that generate the thought and if it is beneficial or useful for her and her health and them change it for another one more positive, she is having those negative thoughts but that is not positive for ber and her health. She has to think that er Srother wil! be better and she ts doing everything to be in. better condition Response/feedback During the session she was very attentive at the end she was quicter and more relax. Psychiatric Progress Note Dated December 12, 2020. R. 1060-61. CHIEF COMPLAINTS Current situation'trigger er concern, Current negative theughts. Current feelings. Current hehavior with intensity and frequency, Last seen Oct 2020 Medication Adjustment... doing ok HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 elements from these: constitutional, psychiatric, neurological, constitutional, musculoskeletal) Past, family, social, medical history (1 of 3) 47 yo Hisp F, being seen for depression and anxiety Stull tense arnl amaows, but keepine a positive attitude Back andankle pan. Ankle swollen Getting water pills ok Sleeping good. Mo side effects weds. Family sdomg well. Pt coping w many stressors. COVID, stay at home order Pam in back and other joints, but airsid to go to doc apgts due to virus. asen, whe shot self 9 vears ago, when he was just 20 years old. This is always in her mind Pt dealing w financials stress. She hurt her back and can no longer work. Pt says she is always sad and anxious, but medications are helping partially. Pthas 2 other ehildcen inthe 2(/s now. Deceased son left Pt a grandson, also named Michael WNRDA HTN, Hemiated Disc, Sciatica , Beck Pain Not pregnant Denies D&A Progress Note Dated December 14, 2020. R. 1062. MOOD CHECKING From one to ten, 1 feel 6 COPING CARD? Mo BRIDGING: in the last session we were talking about my progress with my pains and the importance to be more active " REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “T try to do what we said but is too hard, its helps, but pust a litle bit" Agenda] would like to continue talking about the situetion thet. am having now Educetion about the situation of ler health * ASSESSMENT: A-1 am trying to de the best Out my health is not well, mow the drs are talking that: need surgery think if i have the surgery 1 will not be the same agam "C-I feel worry every single day . crying for the most simple thing, and lastmght 1 was up almost the whole night" MSE: General Evelyn looks worry , with a sad affect mood ok, tp orgarnzed, poor insight poor judement’ DIAGNOSIS Major depressive disovder Recurrent ( 295.20/ F-33.1} Tatervention Therapist worked with Evelyn practicing active listening and validating her feelings, we start to talk about her fears and her woaries because she said that she has been seeing people that they didn’t good after the surgery and another has heen died, was validated because itis rue Sut she has seen a lot of people who has done well and the improvement im the health is huge, was encouraged to keep the appointment because that's the reason of that appointment , It is orientation. Evelyn was motivated to continue with the process to see what is going to be Response/feedback Byelyn was very attentive and was quiet tearful and very angry ia moment Progress Note Dated December 21, 2020. R. 1064. MOOD CHECKING From one toten, i feel 7 COPING CARD? No BRIDGING: in the last session we were talking about my progress with my pains and the importance bo be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: “Ttcy to do what we said but is too hard , its helps , but past a lettle bit! Agenda T been doing @ lot of thongs to have my things well " ASSESSMENT: A: “Tam feeling less depressed. Stull working with my dewehter but not too much because my health problem ". B: "7 beliewe that can get better at managing my thinking". "T stil get depressed two or three times a day ° MSE: General Evelyn looks worry , with a sad affect mood ok, tp onanized, poor insight poor judgment" DIAGNOSIS Major depressive disorder Recurent (296.20! F-33.1) Intervention The therapist continued to werk with Evelyn on adenufying and contaimag unhelpful thoughts. Evelyn was validated she has been deung better she is doing secie job, that’s a pond sten for her , was encouwaged to see how she start and where she is , she understand and see that but the hegative thoughts are been very often. Was encoutaged to increase to The necessary support and encouragement were given ducing session. was practice a relaxation exercise with positive thinking exercise Responseffeedback Evelyn response very quiet end postive and was rewiforced posinve and was encouraged to continue hke that Progress Note Dated December 28, 2020. R. 1066. MOOD CHECKING From one to ten, : feel 6 COPING CARD? No BRIDGING: in the last session we were talking about my progress with my pains and the wmportance to be more active * REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘T try to do what we said but is too hard, 1am practicing the relaxation exercise especially at sleep time andiits helps , but litter bit" Agenda] would like to talk how T will be dealing with this situation because now Iam very meganve “ ASSESSMENT: A- “Iam doing better my health is better and Tam sleeping better, ] will go to Florida ] hope to have a mice tune” Be"T think thes trip will be good for me because been in a lot of stress" C- "Tm feelmg less anxious two tunes a day every day, less depress” General Evelyn looks worry , with a sad aitect mood ok, tp organized, poor insight poor judament" DIAGNOSIS Major depressive disorder Recurrent ( 295,20! F-33.1} Intervention During tie session, the therapist was actively listening, was encouraged to change these negative thoughts for 2 positive once, was talking about her health prodlems Out is not anything that bad, was explamed how her thoughts affect her feelings and the way tat you see the life . Resnonse/feedback Evelyn was very attentive and was quictand relaxes Progress Note Dated January 11, 2021. R. 1068. MOOD CHECKING Frew one to ten, feel 6 COPING CARTY No BRIDGING: in the last session we were talking about the stress at hone and the importance to be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN): ‘T try to do what we said but is too hard, 1 am practicum the relaxation emercise especially at sleep time andaits helps , but a litter bit" Agenda We will be working with her thoughts replacement, negative for positives irrational thought. We will be working education and orientation about what she could do i this situation ASSESSMENT: A- “Tam doing better but my health is not well, [ conte with 2 lot of pain ouimy hipand leg” B-"T think this wall be a Selure. I think thet am going crazy, I think that l have something bad and the doctors doesn't want to tell me nothing and now i can't go to the hospital" C- " I'm feeling very ancdouy two times a week 1 feel like i will have a panic attack. 1 am crying very often .* MSE: General Evelyn looks worry , with a sad affect mood ok, tp ormamzed, poor insight poor judgment" DIAGNOSIS Major depressrve disorder Recurrent (296.20) / #-33.1) Intervention During the phone session, the therapist wes actively listening, was encouraged to increase those negative thoughts for a positeve once, was talking about her health problems but is not anything that bad, she has to think that she has to continue with positive thinking because at least is not something to be in the hospytal , ii just to see how is out side to be thankful te be aloe , was encouraged to practice meditation or mindiulness at the way that we did the last tame we were i the office and do tt at least two times a daw to reduce her anccigas level Response/feedback Syelyn was quiet and cooperative and was remforeed positive and was encowaged to contimue doing what she is doing Progress Note Dated January 18, 2021. R. 1070. MOOD CHECKING From one to ten, : feel & COPING CARD? No BRIDGING: In the last session we were talking about my progress woth my pains and the importance to be more active * REVIEW OF HOMEWORK (WHAT DID YOU LEARN) "Liry to do what we sud but ts too hard , sts helps, but pust a ittle bit" Agenda] want to comtnue tele about how | have to certinue dealing with the situation” ASSESSMENT: A-“T been doing better, but Tam not well, my migrame, back ache end my legs are hitting me so bad “ B-“T think Tam every day worst, my daughter was at home for a few days.* C- “Tam feeling every single day very nervous , somebmes anger and frustrate two or three times a day “ MSE: General Evelyn looks worry , with a sad attect mood ok, tp organized, poor uisight poor judgment" DIAGNOSIS Major depressive chsorder Recurrent (295.20, 33.1) Intervention Climcian used this imervention to analyzes with Evelyn about the importance of being the most postive that she can and avoid those Hulomaitic negative thoughts that con makes her sad and werry and continues bo weit until this situations ends always trying to see thal every negative sttuation fas a solution and that she has to continues bemg motivated Was valideted because she is a good mom anda good grandmother because always she gives a good support to them and that good. Wes encouraged to talk with them to let them know that this is temporal and this also will pass and will have to take the best part of dius sutwation. Response/feedback Evelyn was very attentive end was quict and relaxes. Progress Note Dated January 25, 2021. R. 1072. MOOD CHECKING From one to ten , 1 feel 6 COPING CARD? No BRIDGING: in the last session we were talking about the stress that t have . REVIEW OF HOMEWORK (WHAT DID YOU LEARN): "Ttry to do what we sad but is too hard 1 am practicing the relaxation exercise specially at sleep time and its helps , but a litter bit" Agenda T would like to talk about , what1. will do with all this papers . Problem solving. ASSESSMENT: A-*I am continue very upset and nervous , when, 1 have to do something out of the order , i feel upset” B- “I thie my life is a disaster 2 can’t have a nice and productive person in my life, i thmk he is not doing goed things “ C-“T'm feeling worry every day . anxious, a grade of 5 from | to 10), scare that something bad could happened and also frustrate every day 24/7 MSE: General Evelyn looks worry , with a sad affect mood ok, tp orgamzed, poor insight poor judgment" DIAGNOSIS Major depressive disorder Recurrent ( 296.20, F-33.1) Intervention During the session, the therapist was actively listening her talking ebout the the situation, was validated because she has been dealing, with the situation very well During the session she is describing the reason of her fears end many times they are real because slre has already gone through many situations that have led her to be and think like that. It was orlented that when those thoughts of fear come to your mind changes it for differemt snd positive as everything will be fine and ai] those investigation 15 for aressen Response/feedback Evelyn was very attentive and was quict and relaxes. Psychiatric Progress Notes Dates January 28, 2021. R. 1074. CHIEF COMPLAINTS Current situation trigger or concern, Current negative thoughts, Current feelings. Current behavior with intensity and frequency, Last seen Oct 2020 Medication Adjustment... doing ok HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 elements from these: constitutional, psychiatric, neurological, constitutional, musculoskeletal) Past, family, social, medical history (1 of 3) 47 yo Hisp F, being seen for depression and amaety Stull tense aril anxious, but keeping a positive attimde Back and ankle pain. Ankle swollen, Getting water pills ok Sleeping good. No side effects w meds. Family ts doimg well. □□ coping w many stressors. COVID, stay at home order Pam in back and other joints, but afraid to go to doe apots due to virus. Ft had son, who shot self 9 years ago, when he was pust 20 years old. This is always in her mind. Pt dealirg w financtals stress. She hurt her back and can no longer work. Pt says she ts always sad and anxious, but medications are helping partially. Pt has 2 other children in thei 2(?s now, Deceased son left Pia grandson, also named Michael NEDA HTN, Kemuated Disc, Scighea, Back Pain. Not pregnant Denies D&A, Progress Note Dated February 01, 2021. R. 1076. MOOD CHECKING From one to ten, + feel 6 COPING CARD? No BRIDGING: in the last session we were talking about the stress at home and the importance to be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: “Ttry to do what we satd but is too hard, 1am practicing the relaxation exercise especially at sleep tune amd its helps , but a litter bit" Agenda We will be working thought restructuring with the 3 C's technique Validation of her feelings ASSESSMENT: A-I am trying to be better but my health conte at the same avy knee andimy beck is hurting me □□□ □□□ my Orother is at the again and thats not good " think that] arm met going to be like that for ever" C=] feel bad, sack. frustrate . very anxious sometimes in pamic and that is two or three times a day" MSE: General Evelyn locks worry , with a gad affect mood ok, tp organized, poor insight poor judement" DIAGNOSIS Major depressive disorder Recurrent (296.20) F-33.1) Intervention Durmg the session she was active listen when she wae desccibing her feelings , she 1s mot feeling well but was validated because if she see forward she rshaving good improvement , she has been doing = lot of positive things, but has to continue working with this situation now , this day will be working with the 3 C's technique . evaluate the emotion before the thought and them check if that emotion that generate the thought and if tt is beneficial or useful for her and her health and them change it for another one move positive, she is having those negative thoughts but that is not pesilive for her and ber health She has to think that er Srother will be better and she ts doing everythung to be ma betier condition Response/feedback During the session she was very attentive atthe end she was quicter and more relax Progress Note Dated February 08, 2021. R. 1080. MOOD CHECKING From one to ten, 1 feel 6 COPING CARD? Neo BRINGING: in the last session we were talking about the stress at home and the importance to be move active REVIEW OF HOMEWORK (WHAT DID YOU LEARN): “Ltry to do what we satd but is too herd " Agendal would lke to talk how I will be dealiig with tus situation because now lam very negahye ASSESSMENT: A-“T aim oot well, my health ss at the same,T 1 been thinking too much about my pass son, if 1s another year out of tum “ B-"T think this will be so badi don't know what wall going to be wrth C-" Tin feeling very amacus two or three times a day every day , very depressed and fer no reason two orthree times a day” MSE: General Evelvn looks worry , witha sad aifect mood ok, tp organized, poor insight poor judgment" DIAGNOSIS Majer depressive disorder Recurrent (295.20 / F-33.]} Intervention During the session, the therapist was actively listening, was encouraged to increase those negative thougits for a positive once, was talking about her health problems but is mot anything Thit bed, was explamed how we will go to be working to control her panics Evelyn was encounged to organize and prioritize what she wants to do first-and evaluate the possibility to get it , set short term goals because sometimes If you setclear goals and prioriize what should go first and thea what resources you have, itwill be difficult for you to achieve it. feedback Evelyn was very allentive and was quiet and relaxes. Progress Note Dated February 15, 2021. R. 1078. CHECKING From one toten, i feel 7 COPING CARD? No BRIDGING: In the last session we were talking about the stress with my health issues REVIEW OF HOMEWORK (WHAT DID YOU LEARN»: “[ try to de whet we said but is ton herd" would lice to talk iow I wall be dealing with this sttuation because now Iam very negative * ASSESSMENT: A- “Tam act well, my health is not well. [hid cortisone injection again but the pain still there. “ B-"T think this will be so bad i don’t know what will gomg to be with me." C-"T'nv feeling very anxious two or three times aday every day , very depressed and crying for no reason. two of three tines a day. ” MSE: General Evelyn looks worry , with a gad atfect mood ok, tp orgamzed, poor insight poor judgment” DIAGNOSIS Major depressive disorder Recurrent ( 296.20)/ F-33.1) Tntervention During the session, the therapist was actively Listening, was encouraged to increase those negative thoughts for a positive once, was talking about her health problems but is net anything That bed was explamed how we will po to be working to control her panics. Bvelyn said : "what God want for me ' , we utilize Socratic questions - whet do you think os trying to tell you? -, - what do you think do you need to do now? all this trying to let her get masygit in what seriows is this problem but she has continue working on it. Response/feedback Evelyn was very attentive end was quict and relaxes. Progress Note Dated February 22, 2021. R. 1082. MOOD CHECKING From one to ten, : feel 6 COPING CARD? No BRIDGING: In the last session we were talking about the stress that i have with avy healtit. REVIEW OF HOMEWORK (WHAT DID YOU LEARN: ‘Ttcy to do what we said but is too hard." Agenda This day 1 would like to talk about About itralienal thoughts Validation of her feelings I want to talk about my fears We will be working with the treatment plan for the mext 120 days ASSESSMENT: A- This weekend: was so sad, pust lay bed but on Sunday came my daughter buti am mot well, it wes my grandson birthday and every single day he look a kike more to his father. my pais son, when 1 See Fim is to See my sonal the same age " B- 1 think hat ican't even will do what thought ,1 because 1 want to start towork " C-] fee sad, crying alot, more then two times a dey ,1 am noteven sleeping well" MSE: General Evelyn looks worry , with a gad aftect mood ok, tp organized, poor insight poor judement" DIAGNOSIS Major depressive disorder Recurrent (296.20! F-33. 1s Intervention During the session, the therepist was actively listening to thei fears, about everything, was her prendson birthdey . said itis the same face of her pass son and make her feel bad, but this sttuation is better because her other owe grandchildren are guris and that's the only boy and that good because he 2s not with her any more. 1s good to have him clase was encouraged for these days prepare activities for the family , they could spend tume together .. try to spend the most tame together . she has to work her negative thought, was instructed to think in posite because as more negative thoughts is worse ,every lime a negative thinking hit her mind .think someting positive, Response/feedback Evelyn was active , cooperative and talketive , was swongly reinforced Treatment/Recovery Plan Dated February 22, 2021. R. 1084-86. Diagnosis ( please add the DX) (296.2F/ 33.1) Major depressive Disorder, Recurrent episodes (Undieate Specitie Stressors) Her medical and economical issues Clicnt’s Strengths (Use the one in the Recovery Goal}: Good family support system Challenge to Treatment: Increase her social activities, increase freq to therapy sessions Anticipated Length of Treatment: 3-6 Months For Update Only: (Review of Progress since Last Plan) Update Describe progress During the last 120 dave she gad some progress , her health is better and that sitaation emotionally make her feel hetter CONCERNS -1(What client states problem is, activating event, beliefs, emotions, behavior, relational problems, and somatization) A- This weekend i was so sad , just lay bed but on Sunday came my daughter but i am not well, it was my grandson birthday and every single day he look a hike more to his father, my pass son, wher iace him is to see my som al the same age” Be DL think that iean't even will de what i thought . 1 because 1 want to start to work "-C- | fee sad, erving a lot, more than two times a day, iam nol even sleeping well” Long Term Goal / Discharge Criteria (What will be accomplished by the client at end of treatment) 1- Evelyn will improve her health condition and will continue going to all the appointments and all the studics that she has to do 2- By the next 120. days Evelyn wall be sccing the peychialnc regularly to continue with the medications. Short-ierm Goal; (What will be done over the next 4 months to achieve long term goal.) By the mext 120 days Evelyn will improve her emotional control and will retum te a normal life followme the clinician directions . Modality including medication management & Responsible person The therapist will be working with Evelyn individual therapy and psychiatric for medication check up, Responsible person: the therapist , psychiatric and patient, Interventions The therapist will continue working with CBT. To amplement cognitive restructuring with the 3 C's technique Continue with psycho education .The therapist psyehe educated about the importance the being consistent with her treatment The therapist and Evelyn will work on improving her coping skills to decrease her feeling of anxiety. The therapist will be utilizing validation. Will be practicing relaxation exercise and meditation to reduce her anxious level RECOVERY GOAL/PERSONAL VISION/WHAT TWANT TO ACHIEVE Illness management Family involvement What do T want to work mow/what skills T need, how 7] can use my support system and resources from my community Improve the family communication and avoid my bad feelings (sadamciety) and the self isolation” How Tam going to get there/How my strengths can help me to get there (include cultural values and spiritual beliefs and support system) IN CASE OF CRISIS In case of crisis □ i just want to be alone. slay in my room FACTORS THAT HAVE CONTRIBUTED TO AN INCREASED IN SYMPTOMS When they want me to do a lot of things at the same time . when scamething happen in the family . INDICATOR 8 OF WHEN SYMPTOMS BEGIN TO WORSEN I can't stop cry think too much STRATEGIES THAT CAN BE UTILIZED WHEN EXPERIENCING WARNING SINGS (indicate specific intervention) Watch tv , stay alone. Discharge Plan When Evelyn reduce to the minimal level of depression , when she will learn how te control her emotions in a positive way , will scen monthly for six month and will be de the discharge. . Progress Note Dated March 01, 2021. R. 1088. MOOD CHECKING From. one to feel 6 COPING CARD? No BRIDGING: In the last session we were talking about my progress with my pains and the importance to be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN}: "trey to do what we said but is too hard." Agenda We will be working wath her thoughts replacement; negative for positives wrational thought. pros and cont of the negative attitude. ASSESSMENT: A-“T am trying to do better but my health 1s at the same and last maght: couldn't sleep st all due my pams , the worst thing ismy knee, the ryzht one ts swollen thanks God: will see the orthepedic tormocrow and this day ihed blood work” BH." think the sttuanon is too hard and maybe will net going te be able to work any more “ C-" I'm feeling anxious two times a day every day, depress and last might 1 couldn't sleep at all.” MSE: General Evelyn locks worry , with a sad affect mood ok, tp organized, poor insight poor judgment" DIAGNOSIS Major depressive disorder Recurrent (296.20 /F-33.1) Intervention Today patient was puided by therapist on express about her feelings, has been trough for a lot of medical problem and that sttuation her feel hopeless but she was validated becouse side she has faith and a gond family support to has motivabon to continue , were working with her posthiwe and negative attitude because goes in pros and cont in his emotion We were working with her the umportance of behavior activation , to not to be too much time in bed or lay down in the sofa Response/feedback Eyclyn was very attentive and was quict and relaxes Progress Note Dated March 08, 2021. R. 1090. MOOD CHECKING From one to teri feel 7 COPING CARD? Mo BRIDGING: In the last session we were talking about the stress thet 1 heave with my health REVIEW OF HOMEWORK (WHAT DID YOU LEARN): "Ttry to do what we sand but is too herd." Agendal would like to talk how I will be dealmg with this situation because now Iam very negative “ ASSESSMENT: “Tam dome better but my healthis not well, if comtnue with this back and leg pain .] need to go to the emergency room, □ went the last Saturday and they said my ce has to send me for more test Sut at least they didn't find blood clogs " BL think this will be a failure, [ thimk that I am going crazy, [ think thet I have something bad and the doctors doesn’t want to tell me nothing C- ‘I'm feeling very aimtious two or three times a day every day , very depress end crying for noreason bro or three times a day □ MSE: General Evelyn looks worry . with a sad affect mood ok, tp orgamzed, poor uisight poor judgment" DIAGNOSIS Majer depressive chsorder Recument ( 26.2()/ F-33.1) Intervention During the session, the therapist was actely listening her talking ebout the situation, she could identify some irationel thoughts as “Always have to be sick “was explaining her health problem ated has reasons for her hopeless feeling but was encouraged to change that thought for one as “I have this problem butis not something that ] will died for rt because | am dealing with fora long time” Response/feedback Evelyn was litters bit frustrate at the first but late on was different, very attentive and was quict and relaxes. Progress Note Dated March 22, 2021. R. 1092. MOOD CHECKING From one to ten, i feel 7 uy anxiety has been high COPING CARD? Ne BRIDGING: In the last sesston we were talking about the stress at home and the importance to be more active REVIEW OF HOMEWORK (WHAT DID YOU LEARN): "Try to do what we sad but 1s too hard ." Agenda We will be working thought restructuring with the 3C's technique Validation of her feelings ASSESSMENT: A-°I am aot well, my healthis not well, [ hada cortisone injectton again but the pain still there. * B-°T think this will be so bad1 don't knew whet will going te be withime Tm feebng very anxious two or three times a day every day , very depressed and orymg for no reason two or three times a day. ” MSE: General Evelyn looks worry , with a gad affect mood ok, tp omganized, poor insight poor judgment" DIAGNOSIS Major depressive disender Recument (205. 20)/ F-33.1) Intervention During the session, the therapist was actively listening, was encouraged to increase those necetive thoughts for a positive onde, was talking about her health problems but us not anything That bed, was explamed how we wall go to be working to control her panies. Response/feedback Fyelyn was very attentive and was qutet and relanes. Psychiatric Progress Notes Dated March 25, 2021. R. 1094. CHIEF COMPLAINTS Current situation trigger or concern. Current negative thoughts. Current feelings. Current behavior with intensity and frequency. tense and anxious HISTORY OF PRESENT ILLNESS (4 elements of the sign and symptoms: severity, timing, quality, duration, contest, modifying factors, chronic conditions. Review of system (2 elements from these: constitutional, psychiatric, neurological, constitutional, musculoskeletal) Past, family, social, medical history (1 of 3) 47 yo Hisp F, bemg seen for depression and anaety Picked up meds from Jan Doing good, ok meds helping Still tense and anxious, but keeping a positive attitude Back and ankle pain. Ankle swollen Getting water pills Sleeping good. No side effects w meds. Family is doing well) Pt coping w many stressors. COVID, stay at home order Pain in back and wther joints, but affaid to go to doc apets due to virus. Prhad ason, whe shot self 4 years ago, when he was just 20 years old. This is always in her mand. Ptdealing w financials stress. She hurt her back end.can no longer work. Ft says she is always sad and anxious, but medications are helping partially, Pt has 2 other children in their 2(’s now. Deceased son left Pta grandson, also named Michael NEDA HTN, Hemuated Disc, Sciatica, Hack Pain. Not preenant D&A — 43 —