Progress Review Note (Clinical Hypnosis)

Progress Review Note – Clinical Hypnosis

Patient Name: [Patient name]

Date of Service: [Date]

Author/Credentials: [Name, credentials]

Setting/Modality: [outpatient / inpatient]; [in-person / video / phone]

Review Interval: [Start date] to [end date] ([number] sessions)

Reason for Review

[Trigger for this review and primary aims] (One to two sentences; e.g., scheduled reassessment, plateau, symptom flare, or payer requirement; state goals such as evaluate response, revise goals, adjust hypnosis plan.)

Interval Progress

Active diagnoses/problems addressed with hypnosis: [List active diagnoses and problems targeted during this interval]

Symptom trajectory since last review: [Change in targeted symptom domains with frequency/severity trends] (Use measurement-based language; indicate improved/unchanged/worsened for each domain.)

Functional status: [Changes in work/school, ADLs, social functioning, activity tolerance, or other relevant domains]

Home practice adherence: [Techniques assigned and expected frequency] — [estimated completion rate] — [patient-reported benefit] — [barriers if adherence suboptimal and plan to address]

Outcome Measures & Goals

Standardized measures:

• [Measure name] — [date]: [score] ([improved / unchanged / worsened])
• [Additional measures as applicable]

(If measures were not collected, state why and plan to obtain.)

Goal attainment status:

• [Goal 1] — [met / partially met / not met / deferred]: [brief supporting evidence]
• [Additional goals as applicable]

Assessment

Clinical formulation: [Problem-oriented synthesis linking current symptoms, function, and outcome measures for each active problem; indicate status as improving/stable/worsening; note drivers or maintainers] (Address each active problem; integrate symptom trends, functional impact, and measure results.)

Hypnosis interventions this interval: [Primary targets and core techniques used; patient responsiveness and tolerance] (Avoid verbatim scripts or detailed imagery content.)

Safety: [Risk assessment completed] — [no acute concerns / concerns noted with basis] (If hypnosis-related adverse responses occurred—panic, dissociation, abreaction—document event, management, and safeguards implemented.)

Plan

• Continue: [Elements to maintain]
• Change: [Modifications to current approach]
• Add: [New techniques or supports]
• Stop: [Elements to discontinue]

(Use only categories that apply; omit categories with no content.)

Goals (revised/reaffirmed): [Behavioral, measurable goal statements]

Home practice prescription: [Technique(s), frequency, duration, and tracking method]

Coordination: [Communication with other providers] (Include only if applicable.)

Next reassessment: [Date or criteria for next progress review]