[Practitioner's Full Name and Title]
Dr. Eleanor Vance
CONSULTANT PSYCHIATRIST
1 November 2024
,Diagnosis:,
* Major Depressive Disorder, recurrent, severe, with psychotic features
* Generalised Anxiety Disorder
,Medications:,
* Sertraline 100mg daily
* Quetiapine 100mg nocte
Thank you once for your ongoing referral for me to see John who presents today to see me for ongoing management of his mental health.
John is a 38-year-old married man who lives with his wife and two children. He has been experiencing significant difficulties with his mood and anxiety over the past year.
John presented to the clinic today looking dishevelled and withdrawn. He was accompanied by his wife, who provided additional context to his presentation. He made minimal eye contact and spoke in a quiet, monotone voice. He appeared to be somewhat agitated, wringing his hands throughout the consultation.
John reports a persistent low mood, with feelings of worthlessness and hopelessness. He states, "I feel like I'm a burden to everyone." He has experienced significant changes in his sleep, appetite, and energy levels. He reports sleeping for 10-12 hours a night but still feeling exhausted. He has a poor appetite and has lost weight unintentionally. He has also reported suicidal ideation, stating, "I don't see the point in going on." He denies any current suicidal plan or intent. He also reports significant worry and anxiety, particularly about his finances and his health. He reports feeling restless and unable to concentrate. He has also reported panic attacks.
John's depression has been treated with Sertraline 100mg daily, which has provided some benefit, but his mood remains significantly low. He has also been prescribed Quetiapine 100mg nocte for his psychotic symptoms and sleep. He reports that the medication has helped with his sleep, but he still experiences auditory hallucinations. He has been attending weekly psychotherapy sessions, which he finds helpful. I have advised increasing the Sertraline to 150mg daily and continuing with his current psychotherapy. I have also advised him to seek support from his family and friends.
John's social and functional status has been significantly impacted by his mental health. He has withdrawn from social activities and has difficulty maintaining his work. He is currently on sick leave from his job. His wife provides significant support, helping with household duties and childcare. He is not currently receiving any support from NDIS.
John has no significant physical health issues.
On review of his recent investigation results [01/10/2024], I noted the following:
* FBC: Within normal limits.
* U&Es: Within normal limits.
* LFTs: Within normal limits.
Hence, at the conclusion of this appointment, my intentions for further management include the following:
1. Increase Sertraline to 150mg daily.
2. Continue with current psychotherapy.
3. Encourage John to attend a support group.
4. Schedule a follow-up appointment in four weeks to monitor his progress.
I have advised John to continue taking his medications as prescribed and to attend his psychotherapy sessions. I have also encouraged him to reach out to his support network and to contact me if his symptoms worsen. I have also advised him to maintain a healthy lifestyle, including regular exercise and a balanced diet.
Thank you once again for referring John to see me and I will keep you informed of his progress.
Dr. Eleanor Vance
Consultant Psychiatrist
[Practitioner's Full Name and Title]
CONSULTANT PSYCHIATRIST
[Date of Note] (use format: DD Month YYYY)
Diagnosis:
[write a list of diagnoses in dot points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications:
[write a list of medications in dot points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you once for your ongoing referral for me to see [the patient's first name] who presents today to see me for ongoing management of [his/her] mental health.
[Introduction] (Begin with a brief description of the patient, including their age, marital status, and living situation. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Presentation in Clinic] (Provide a description of the patient's physical appearance during the clinic visit. Include anyone who they attended the clinic with. Include observations about their appearance, demeanor, and cooperation. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mood and Mental State] (Provide a paragraph describing the details of each of the patient's diagnoses. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If they have a diagnosis of depression or bipolar disorder describe the patient's mood as reported during the visit. Include details about their general mood stability, any thoughts of worthlessness, hopelessness, shame, guilt, isolative behaviour, low self-esteem, or suicidal ideation, intent or plan. Provide details of sleep, appetite, energy, motivation, memory. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If there is a diagnosis of ADHD, provide details of inattention such as misplacing items, struggling with focus and attention, distractibility, procrastination, poor organisation, poor planning, poor initiation or completion of tasks, struggles to listen when spoken to directly. Describe any features of hyperactivity such as fidgeting, leaving seat in situations they are meant to remain seated, restlessness, always on the go or "driven by a motor" and can't rest, talks excessively, can't wait their turn, blurts answers, butts into conversations, interrupts others, or does impulsive behaviours. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If there is a diagnosis of PTSD detail any features such as re-experiencing the trauma, nightmares, or flashbacks. Detail any features of hyperarousal such as hypervigilance, increased startle response, irritability, isolative behaviour, insomnia. Detail whether there have been problems with numbing of emotions or features of avoidance caused by the traumatic experience. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If there is a diagnosis of an anxiety disorder detail whether it is characterised by generalised apprehension, poor concentration, agitation, restlessness, fatigue, muscle tension, insomnia, ruminations, panic attacks, social anxiety, or agoraphobia. If there is a diagnosis of OCD indicate what the obsessive thoughts are, and what repetitive or ritualistic compulsions are occurring. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(This section must be written in several paragraphs of full sentences. Write at least 1 separate paragraph for each of the patient's listed diagnoses. Do not use bullet points or lists. Allow patient's quotes. Also include information about whether any of their treatment has helped, how medications have been tolerated, which psychological interventions have assisted. Also record what changes to treatment I have advised. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Social and Functional Status] (Discuss the patient's social relationships and their level of function in daily activities. Include information about their relationship with significant others, their participation in programs like NDIS, and their ability to manage household duties. If the patient receives help from others, such as a spouse, describe this support. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical Health Issues] (Mention any physical health issues the patient is experiencing, such as obesity or arthritis. Include advice given to the patient about managing these conditions. Do not include mental health issues in this section. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists. Keep this section quite brief. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
On review of [his/her] recent investigation results [put in the date of the blood tests (DD/MM/YYYY)], I noted the following:
[put in the details of the blood test or investigations results mentioned. Write this section using dot points with brief statements, numerical results, or brief sentences for scan results. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hence, at the conclusion of this appointment, my intentions for further management include the following:
[Plan and Recommendations] (Outline the agreed-upon treatment plan based on the discussion with the patient and any accompanying individuals. Include recommendations to continue with current medications, ongoing programs like NDIS, and any other health advice provided, such as maintaining adequate water intake. Also include a plan for follow-up visits to monitor the patient’s mental health stability. You may list this part in numbered bullet points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Closing Statement] (Include any final advice or recommendations given to the patient. This section must be written in full sentences as a cohesive paragraph. Do not use bullet points or lists. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you once again for referring [the patient's first name] to see me and I will keep you informed of [his/her] progress.
[Practitioner's Full Name and Title] (Write Dr without a full-stop)
Consultant Psychiatrist
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)