Date:
Patient:
MRN:
Clincian: (Therapist, Psychiatrist)
Reason for Visit:
Follow-up for GAD
Evaluation of symptoms and response to treatment
Discussion of coping mechanisms and progress
History of Present Illness:
Briefly describe the patient’s current experience with GAD:
Duration of GAD symptoms (excessive worry, restlessness, fatigue, muscle tension, difficulty concentrating)
Frequency and severity of symptoms
Impact of symptoms on daily life (work, relationships, social activities)
Response to previous treatment approaches (therapy, medication)
Past Medical History:
Mental health history (depression, OCD) – may co-occur with GAD
Medical conditions relevant to treatment considerations (e.g., medication interactions)
Social History:
Stressful life events or ongoing stressors contributing to anxiety
Social support system (family, friends)
Mental Status Exam:
Briefly describe the patient’s mood, affect, and thought processes.
Assess for suicidality if indicated.
Assessment:
Summarize the diagnosis:
Confirmation of GAD diagnosis based on DSM-5 criteria.
Severity of GAD symptoms using a standardized scale (e.g., GAD-7).
Plan:
Outline the treatment plan based on the patient’s progress and goals:
Psychotherapy:
Cognitive Behavioral Therapy (CBT) – focuses on identifying and challenging negative thought patterns and developing coping skills for managing anxiety.
Other evidence-based therapies (e.g., Acceptance and Commitment Therapy – ACT) may also be considered.
Medication:
Selective serotonin reuptake inhibitors (SSRIs) – may be considered for moderate to severe GAD or if CBT alone is insufficient.
Discuss benefits and risks of medication with the patient.
Relaxation techniques:
Mindfulness meditation, progressive muscle relaxation, deep breathing exercises.
Lifestyle modifications:
Regular exercise, healthy sleep hygiene, balanced diet.
Prognosis:
Briefly discuss the prognosis. GAD is a chronic but treatable condition. With effective treatment, many people with GAD experience significant improvement in their symptoms and quality of life.
Emphasize the importance of ongoing therapy and self-management strategies.
Education:
Document any education provided to the patient regarding:
The nature of GAD and its symptoms
The importance of identifying and managing triggers for anxiety
The benefits of therapy and relaxation techniques
Strategies for promoting healthy sleep and lifestyle habits
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication, therapy, or managing their anxiety.
Consider the patient’s readiness and preferences for treatment approaches.
Document informed consent discussions for any treatment interventions.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a mental health professional for diagnosis, treatment recommendations, and prognosis.