General Practitioner-Vorlage
2715/2712
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This template, designed for General Practitioners, streamlines the creation of detailed mental health assessments. It's perfect for documenting patient history, including presenting complaints, substance use, psychiatric history, medications, social factors, and family history. The template guides the GP to formulate an impression and create a comprehensive plan, including lifestyle changes, medication adjustments, and referrals. With Heidi, this template can be quickly populated from a patient consultation, ensuring accurate and efficient clinical documentation. This template helps GPs create thorough and compliant mental health notes, saving time and improving patient care.
Vorlagenvorschau
"Patient consented to AI scribe and Mental Health Care Plan"
"Aware of schedule of fees"
History of Presenting Complaint (HOPC):
* Mood: Low mood for the past 6 months.
* Anhedonia: Loss of interest in activities.
* Sleep: Difficulty sleeping, waking up early.
* Thoughts of guilt or worthlessness.
* Energy levels: Low energy levels.
* Suicidal thoughts: Occasional thoughts of suicide, no attempts.
The patient's symptoms have gradually worsened over the past six months. The low mood and anhedonia are persistent, and the sleep difficulties have become more frequent. The patient reports that the suicidal thoughts are fleeting but concerning.
The patient is experiencing significant stress due to financial difficulties and relationship problems.
Alcohol and Other Drugs (AOD):
* Drinks alcohol occasionally, about once a week.
* Smokes 10 cigarettes a day.
* No illicit drug use.
Psychiatric History:
* Major Depressive Disorder
* Anxiety Disorder
Medication and Allergies:
* No known allergies.
* Sertraline 50mg daily.
Social History:
* Renting a flat, lives alone.
* Single.
* Employed as a teacher.
Family History:
* Mother has a history of depression.
Impression:
Patient presents with symptoms consistent with Major Depressive Disorder and co-morbid Anxiety Disorder. Risk stratification is low to moderate, with suicidal ideation present but no active plans or attempts. Further assessment and intervention are required.
Plan:
* Continue Sertraline 50mg daily.
* Referral to a psychologist for Cognitive Behavioral Therapy (CBT).
* Encourage regular exercise and a healthy diet.
* Discussed the importance of social support and connecting with friends and family.
"Safety planning
1. Self-soothing (distraction techniques, breathing exercises, mindfulness or exercise)
2. Phone a friend (family, friends or partner)
3. Organisations (Lifeline 13 11 14, Samaritans 0863 839 850, MHERL 1300 555 788)
4. Go to ED"
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