AI Treatment Plan for PMHNPs Using ICANotes

TREATMENT PLAN CLIENT INFORMATION: Plan Date: [Date] Review Date: 90 days from plan date DIAGNOSIS: Axis I: - Major Depressive Disorder, Recurrent, Moderate (F33.1) - Generalized Anxiety Disorder (F41.1) PRESENTING PROBLEMS: 1. Depressed mood affecting daily functioning (PHQ-9: 18) 2. Excessive worry interfering with sleep and concentration (GAD-7: 14) 3. Social withdrawal and isolation (attending 0-1 social activities per month) 4. Decreased occupational functioning (missing deadlines, difficulty concentrating) STRENGTHS: - Strong insight and motivation for treatment - Supportive partner - Stable employment and housing - Previous positive response to therapy - College-educated with good verbal skills TREATMENT GOALS AND OBJECTIVES: GOAL 1: Reduce depressive symptoms to minimal/remission levels - Objective 1.1: PHQ-9 score will decrease from 18 to below 10 within 12 weeks - Intervention: Cognitive behavioral therapy - cognitive restructuring - Intervention: Behavioral activation protocol - Frequency: Weekly 50-minute sessions - Responsible: Therapist and client - Objective 1.2: Client will identify and challenge 3 negative automatic thoughts per week - Intervention: Thought record homework assignments - Frequency: Daily practice - Responsible: Client with therapist review GOAL 2: Manage anxiety effectively - Objective 2.1: GAD-7 score will decrease from 14 to below 8 within 12 weeks - Intervention: Progressive muscle relaxation training - Intervention: Cognitive restructuring for worry - Frequency: Weekly sessions with daily home practice - Responsible: Therapist and client - Objective 2.2: Client will utilize relaxation techniques when anxiety exceeds 5/10 - Intervention: Skills training and practice - Frequency: As needed, review weekly - Responsible: Client GOAL 3: Increase social engagement and reduce isolation - Objective 3.1: Client will attend 2+ social activities per week within 8 weeks - Intervention: Behavioral activation - social activity scheduling - Intervention: Social skills review as needed - Frequency: Weekly planning and review - Responsible: Client with therapist support - Objective 3.2: Client will initiate contact with supportive friend/family 3x weekly - Intervention: Support system mapping and engagement planning - Frequency: Weekly - Responsible: Client TREATMENT MODALITY: Individual psychotherapy (CBT) FREQUENCY: Weekly 50-minute sessions ESTIMATED DURATION: 16-20 weeks REVIEW DATE: 90 days from start CLIENT PARTICIPATION IN TREATMENT PLANNING: Client participated in development of this treatment plan, agrees with goals and objectives, and consents to treatment as outlined. Signatures: Client: _________________ Date: _______ Therapist: _________________ Date: _______