Injury Rehabilitation Mental Skills Session Note

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time / Not applicable] (Required for time-based billing; if unavailable, enter "Not documented — [reason]")

Patient: [Name / ID]

Setting/Modality: [clinic / training room / telehealth] — [in-person / video / phone]

Provider: [Provider name, credentials, role] (Include supervisor if applicable)

Participants: [patient only / patient + parent/guardian / patient + rehab staff] (Specify names and roles for non-patient participants)

Referral Source & Injury Context: [Referrer] — [Injury/surgery, side/region, rehab phase/week]

Service Type: [clinical behavioral health/psychotherapy / mental skills/performance support]

Information Sharing Status: [Authorized contacts and scope / None authorized / Patient declined] (Reference authorization if applicable)

Session Focus

[Primary session focus in patient's words or clinician summary, linked to current injury/rehab phase] (1–3 sentences)

Subjective

Injury/Rehab Status: [Patient report of current function, symptoms, and changes since last visit] (Include only if assessed)

Psychological Response: [Fear of re-injury, mood, identity concerns, catastrophic beliefs, confidence/readiness ratings with task-specific context] (Include ratings 0–10 when obtained; specify task and triggers)

Adherence: [Patient-reported adherence behaviors with measurable details; identified barriers as practical/psychological/medical; staff confirmation if obtained and clearly labeled as such] (Include only if assessed)

(Omit any category not assessed rather than leaving blank)

Objective

[Brief clinician observations relevant to function, engagement, or safety] (Do not include full MSE unless changes warrant)

[Structured measures if used: instrument, score, date, interpretation] (If expected measure not obtained, note reason)

Assessment

Formulation: [Succinct narrative linking injury context → psychological response → behavioral consequences → rehab impact]

Priority Problems: [Current problems with status and progress since last visit; e.g., task-specific avoidance, adherence barriers, mood/identity disruption]

Diagnosis: [Diagnosis if within scope / Focus is rehabilitation-related adjustment and skill building]

Risk: [No acute concerns endorsed / Risk identified — details and plan / Not assessed — reason] (Document only what was explicitly assessed)

Interventions

• [Technique] — Target: [problem/barrier] — Response: [patient engagement/skill acquisition]
• [Technique] — Target: [problem/barrier] — Response: [patient engagement/skill acquisition]

(Add rows as needed; avoid vague descriptors like "supportive counseling")

Plan

Patient Actions: [Home practice assignments with frequency/context; exposure tasks with parameters and coping strategy; escalation guidance if symptoms worsen]

Clinician/Team Actions: [Coordination with rehab team per consent status; follow-up timing and focus; referrals if indicated]

Electronic Signature: [Name, credentials, date/time]

Supervisor Attestation: [Supervisor name, credentials, attestation statement, date/time] (Include only if supervision applies)