PIRP Note Example: Trauma from Medical Procedures

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Problem:
Client presented with anxiety related to recurring memories of a past medical procedure. Client stated 'I just shut down whenever I think about it' and reported physical symptoms such as tension, racing heart, and difficulty breathing when recalling the event.

Intervention:
During the 45-minute office session, the therapist introduced a five senses grounding exercise to help the client manage overwhelming feelings associated with their medical trauma.

Response:
Client practiced the grounding technique and exhibited signs of relaxation. They appeared to be more at ease with a new strategy to cope with intrusive memories.

Plan:
Client was assigned the task of using the grounding technique as homework when memories arise. The therapist and client will reconvene next week to assess the effectiveness of the intervention and potentially explore deeper emotional responses.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

We had a 45-minute office session today, and the client came in looking pretty anxious, talking about how memories from a past medical procedure have been coming up more and more lately. They said quote 'I just shut down whenever I think about it' unquote and described how it’s affecting them physically, too—like they get tense, their heart starts racing, and they feel like they can’t breathe. We talked about how medical trauma can sometimes be just as intense as other types of trauma, even though people don’t always recognize it that way.

We spent some time going over a grounding technique that could help them stay present when those memories come up, because they’ve been feeling pretty overwhelmed. I walked them through the five senses grounding exercise—focusing on what they can see, hear, touch, taste, and smell to bring them back to the present. They seemed to relax a bit once we practiced that. Their homework is to try using that technique whenever they feel those memories creeping up, just to see if it helps them stay grounded. By the end of the session, they seemed a little more at ease, like they finally had something concrete to try. We’ll meet again next week to see how it’s going and maybe start digging into some of the deeper emotional stuff after they’ve had a chance to try out the grounding.

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More About PIRP Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about PIRP notes.