The following material is a collection of annotated chart notes taken from typical events in daily treatment schedules at
the NCW. While the material is factual, details and identification have been altered to protect identities. Most case descriptions are composite in
nature to protect identities, but are illustrative of the problems treated, clinical experience, and outcomes.
The format gives some Background, the reason for entering treatment, and response (or lack of response) to treatment through that Session. Session notes
include patient report since last treatment, therapist’s observations, as well as recommendations and referrals for other treatments, treatment goals/plans.
An Update section follows these.
Reasons for treatment include: Depression, Insomnia, Fatigue, Dizziness, Anxiety, Asperger’s syndrome, (Autism), Pain, Headache, Auditory hallucinations, Explosiveness, Fibromyalgia, Traumatic Brain Injury, ADHD, Shyness, Non-restorative Sleep, Cognitive Processing Problems, Chemobrain, and Stroke.
Abbreviations: Tx – treatment; Sx – symptoms; Pt. – patient; MVA – motor vehicle accident; TBI – traumatic brain injury; PTSD – post-traumatic stress disorder; FMS – fibromyalgia syndrome, sEMG –surface electromyography, r/o –rule out.
Treatment Notes by Dr. Mary Lee Esty
Treatment Notes by Emily Perlman
