Note Examples
Example PIE Note

Example PIE Note

PROBLEM

Presentation:

  • Chief Complaint: The client presented with a depressed mood, low motivation, loneliness, and difficulty connecting with others.
    • Quote (Chief Complaint): "I don't know, some days I'm just feeling horrible.”
  • Impairments And Challenges: The client described impairments in motivation, engagement in previously enjoyed activities like making music, and establishing meaningful relationships. Their isolation and loneliness appeared to exacerbate their depression.
    • Quote (Impairments And Challenges): "I just feel so miserable.”

Psychological Factors:

  • Symptom 1:
    • Symptom Description: Depressed mood most of the day, nearly every day.
    • Onset: Ongoing, no specific onset provided.
    • Frequency: Daily.
    • Ascendance: No improvements reported.
    • Intensity: Moderate to severe.
    • Duration: Several years per client report.
    • Quote (Symptom): "I’m always seeing things I know I can’t do. It feels heavy.”
  • Symptom 2:
    • Symptom Description: Low motivation and withdrawal from previously enjoyable activities.
    • Onset: Gradual, no specific onset provided.
    • Frequency: Daily.
    • Ascendance: No improvements reported.
    • Intensity: Moderate to severe lack of motivation.
    • Duration: Several years per client report.
    • Quote (Symptom): "I just go places where there's no one and sit there alone.”

Social Factors:

  • Traumatic Experiences: Father passed away when client was a child without knowing for 3 days.
    • Quote (Traumatic Experiences):"My father died alone and no one knew for 3 days, it was horrible."

INTERVENTIONS

  • Therapeutic Approach Or Modality: Cognitive-behavioral therapy, interpersonal therapy
  • Psychological Interventions:
    • Validated feelings.
    • Encouraged challenge of automatic thoughts.
    • Assigned thought tracking.
  • Rationale: Increase awareness of cognitive distortions fueling depression. Begin the process of identifying and challenging automatic negative thoughts.

EVALUATION
Risk Assessment

  • Risks Or Safety Concerns: No safety concerns or risks were reported, stated, implied, or observed during the session.
  • Hopelessness: No statements indicating hopelessness were reported, stated, implied, or observed during the session.
  • Suicidal Thoughts Or Attempts: No suicidal thoughts, plans or intent were reported, stated, implied or observed during the session.
  • Self Harm: No self harming behaviors were reported, stated, implied or observed during the session.
  • Dangerous To Others: The client did not appear to pose any danger to others. No threats or violence were reported, stated, implied or observed during the session.
    • Quote (Risk): "I am not having any thoughts of hurting myself or others. I feel safe and stable at this time."
  • Safety Plan: No safety plan was indicated or developed during this initial session.