OAMHU RCH Progress Note

"The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks." **IDENTIFYING INFORMATION:** Jane Doe, [insert age] years old, single, living in a group home, unemployed, and receiving disability benefits. Referral source: Dr. Smith, primary care physician. Patient's personal health number: 1234567890. **COLLATERAL INFORMATION:** Collateral information was provided by Nurse Johnson. Nurse Johnson reported that the patient has been increasingly withdrawn and has expressed feelings of hopelessness over the past week. **INTERIM PROGRESS:** Jane Doe was assessed today with Dr. Kelly present. Jane reports feeling sad and anxious most of the day. She states, "I just don't see a point anymore." She has difficulty sleeping, often waking up in the middle of the night. Her appetite is decreased, and she has lost some weight. She reports feeling tired and having no energy to do her daily activities. She denies any suicidal ideation or self-harm. She is taking her medications as prescribed. She is attending group therapy and individual therapy sessions. She is concerned about her future and her ability to live independently. She is hopeful that her medication will help her feel better. She understands her treatment plan and is willing to continue with it. **Mental Status Examination:** Appearance: The patient was dressed in clean but slightly disheveled clothing. Her hygiene appeared adequate. Behavior: The patient was restless and fidgety during the interview. She made limited eye contact. Speech: The patient's speech was slow and soft, with occasional pauses. Mood: The patient reported feeling sad and hopeless. Affect: The patient's affect was congruent with her stated mood, appearing sad and constricted. Thoughts: The patient expressed negative thoughts about herself and her future. She denied any delusions or hallucinations. Perceptions: Patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations. Cognition: The patient was oriented to person, place, and time. Her memory appeared intact. Insight: The patient demonstrated some insight into her condition, acknowledging her symptoms and the need for treatment. Judgment: The patient's judgment appeared to be impaired, as she expressed difficulty making decisions. **Impression:** The patient presents with symptoms consistent with a major depressive disorder. She exhibits significant sadness, hopelessness, and anxiety. Her presentation is marked by withdrawal, sleep disturbance, and decreased appetite. The patient's insight is limited, and her judgment is impaired. **Plan:** Certification: The patient's disability paperwork was reviewed. Safety: The patient will continue to be monitored for suicidal ideation. A safety plan will be reviewed with the patient. Biological (including Medications): Continue current medication regimen, including [medication name] at [dosage]. Share-care: The patient will continue to attend group and individual therapy sessions. Psychosocial: The patient will continue to attend group and individual therapy sessions. Disposition: The patient will be scheduled for a follow-up appointment in one week.