Guide
Guide | Reference

40  Documentation Examples

Optional reference material; not required for routine use.

Purpose. Show how the framework appears in actual notes. Provide examples across complexity levels and settings.

40.1 Example Types

  • 1-minute follow-up note.
  • 5-minute evaluation note.
  • Comprehensive assessment note.
  • Compact recording format line.

40.2 Selection Criteria

  • Include mixed domain profiles and comorbidity realism.
  • Include at least one example with diagnostic uncertainty.
  • Include at least one example with high-risk modifiers.
  • Include one ambiguous case with competing explanations.
  • Include one example where no prototype is assigned.
  • Include one primary care style example.

Documentation Output. Example notes linked to their templates. Notes labeled as illustrative only.

40.3 Examples (illustrative only)

40.3.1 1-Minute Follow-Up Note

  • Presenting: “Still having panic surges in crowds.”
  • Safety: suicide/self-harm none reported; violence risk low; self-care intact.
  • Domains (0-4): Threat 3, Arousal/Sleep 2.
  • Specifiers: episodic; contributor: caffeine; risk: low; context: work stress.
  • Prototype: Panic Pattern (provisional).
  • Monitoring: panic count weekly; sleep diary.
  • Snippet: “Episodic panic with avoidance; Threat 3, Arousal 2; episodic course.”

40.3.2 5-Minute Evaluation Note

  • Presenting: “Low mood, low energy, and early waking for 6 weeks.”
  • Context: job loss and housing uncertainty.
  • Atlas: affect/mood and sleep disruption.
  • Domains (0-4): Mood/Drive 3, Arousal/Sleep 2, Threat 1.
  • Specifiers: course episodic; contributors: sleep disruption; risk: low; context: acute stressor.
  • Prototype: Major Depressive Episode (provisional).
  • Uncertainty: consider grief-related response vs mood episode.
  • Monitoring: brief mood scale at each visit; reassess in 4 weeks.
  • Snippet: “Sustained low mood with reduced drive; Mood/Drive 3; episodic course.”

40.3.3 Comprehensive Assessment Note

  • Presenting: “Intrusions, nightmares, and avoidance after assault.”
  • History: prior trauma; sleep disruption; intermittent dissociation.
  • Domains (0-4): Trauma/Stress 3, Threat 2, Arousal/Sleep 2, Mood/Drive 1.
  • Specifiers: chronic course; contributor: ongoing safety concerns; risk: moderate (passive SI, no plan); context: ongoing threat exposure.
  • Prototype: PTSD Pattern (provisional).
  • Competing explanations: rule-out substance effects; rule-out sleep disorder.
  • Monitoring: trauma symptom checklist monthly; sleep log.
  • Snippet: “Trauma-linked intrusions with avoidance; Trauma/Stress 3; chronic course.”

40.3.4 Ambiguous Presentation (Competing Explanations)

  • Presenting: “Wired, irritable, sleeping 4 hours, cannot focus.”
  • Context: rotating shift work; high caffeine; recent stimulant dose increase.
  • Domains (0-4): Arousal/Sleep 3, Mood/Drive 2, Cognitive Control 2, Threat 1.
  • Specifiers: fluctuating course; contributors: sleep/circadian mismatch, stimulant; risk: low.
  • Prototype: deferred.
  • Competing explanations: medication effect vs sleep deprivation vs hypomanic shift.
  • Monitoring: sleep log; review substances/meds; reassess 2-4 weeks.
  • Snippet: “Arousal/Sleep 3 with cognitive control strain; prototype deferred; competing explanations noted.”

40.3.5 Dimensional-Only Note (No Prototype Assigned)

  • Presenting: “Longstanding pain and fatigue, worried about what it means.”
  • Context: ongoing medical evaluation; caregiver stress.
  • Atlas: somatic distress and interoception.
  • Domains (0-4): Somatic Distress 3, Arousal/Sleep 2, Threat 2, Mood/Drive 1.
  • Specifiers: chronic course; contributors: sleep disruption; risk: low; context: caregiving strain.
  • Prototype: none assigned.
  • Monitoring: symptom burden scale; function check monthly.
  • Snippet: “Somatic distress dominant without clear prototype; Somatic Distress 3; chronic course.”

40.3.6 Primary Care Brief Note

  • Presenting: “Palpitations, gastrointestinal upset, poor sleep, high stress.”
  • Setting: primary care visit.
  • Domains (0-4): Threat 2, Somatic Distress 2, Arousal/Sleep 2.
  • Specifiers: episodic course; contributors: caffeine, stress; risk: low; context: new infant at home.
  • Prototype: Panic Pattern (provisional).
  • Competing explanations: medical contributors considered if indicated; rule-out compendium referenced.
  • Monitoring: brief anxiety and sleep measures; follow-up in 4-6 weeks.
  • Snippet: “Stress-linked bodily alarm; Threat 2, Arousal 2; provisional panic pattern.”

40.3.7 Compact Recording Format

  • Presenting: panic + insomnia + avoidance.
  • Domains (0-4): Threat 3, Arousal/Sleep 2, Mood/Drive 1.
  • Prototypes: Panic Pattern (provisional).
  • Specifiers: episodic; contributor: caffeine; risk: low; context: job loss.
  • Trajectory: fluctuating.
  • Confidence: medium.
  • Monitoring: panic count weekly; reassess 4-6 weeks.