Note Examples
Example PIRP Note

Example PIRP 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."

Risk Assessment:

  • Risks Or Safety Concerns: No risks or safety concerns identified.

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.

RESPONSE

Progress and Response:

  • Response To Treatment: The client displayed limited engagement and motivation for change.
  • Specific Examples Or Instances: Client keeps deflecting from talking about certain issues.
    • Quote (Progress): "I don't know, I don't think I can."
  • Challenges To Progress: Lack of motivation and avoidance of social connections will likely impede progress. Negative automatic thoughts and cognitive distortions will also pose a challenge.
  • Therapist Observations And Reflections: Client is fused with their negative thoughts, might need to introduce defusion techniques.
  • Therapeutic Alliance: The client showed some resistance. She was hesitant to talk about certain things related to her anxiety. The therapist processed that with her.

PLAN
Follow-Up Actions And Plans:

  • Homework: Complete thought records identifying automatic negative thoughts and labeling cognitive distortions. Engage in one social activity.
  • Plan For Future Session: Review thought records, continue cultivating motivation and self-efficacy, begin discussing behavioral activation steps.
  • Plans For Continued Treatment: Continue weekly therapy, consider psychiatric referral if lack of progress.
  • Coordination Of Care: No coordination of care indicated at this time.