Mental Health Care Plan COMPLETE NOTE

(Provide granular detail. Use as many issues and bullet points as necessary to ensure clinical information is adequately organised for easy reading comprehension. Use UK English spelling and Australian AEST date and time. Use medical terminology where possible including commonplace GP abbreviations and acronyms.) **Consult Summary:** **[summary of the entire consult including a brief plan and an abbreviated psychiatric formulation addressing why this is happening to this patient, in this situation, at this time.]** (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as two concise lines in handover style.) MENTAL HEALTH CARE PLAN Reason for Presentation [Presenting problem or reason for attendance] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) History of Presenting Problem and Impact: [Details of current mental health symptoms including onset, duration, severity, and exacerbating and relieving factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form. Where possible and relevant, use direct quotes from the patient to express the severity or significance of their symptoms.) [Impact of mental health symptoms on daily activities, work or study, relationships, self-care, sleep and appetite] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Past Medical History: [Past mental health diagnoses, hospitalisations, treatments and treatment response, as well as past or current medical comorbidities and any significant medical issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Medications: [Current or past medications including psychotropics and all other medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Family History: [Family history of mental health illness] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Social History: [Developmental history, childhood history, past traumas, living arrangements, relationships, work or study, and psychosocial stressors] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Substance Use: [Alcohol, smoking, vaping and recreational drug use] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Mental State Examination: [Mental state examination findings including appearance, behaviour, speech, mood, affect, thought form, thought content, perception, cognition, insight and judgement] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write with bold subheadings for each domain assessed. Only include domains that were assessed.) Outcome Measures: [Outcome measures administered and results including measure name, date administered and score] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Diagnosis: [Succinct diagnosis utilising the DSM-5 and relevant axis] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Formulation: [Case formulation incorporating the four P's: predisposing factors, precipitating factors, perpetuating factors and protective factors, as well as a risk assessment rated as low, medium or high risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Goals of Treatment: [All patient and clinician derived goals for the Mental Health Care Plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form. Use direct patient quotes where relevant.) Management Plan: Psychoeducation: [Psychoeducation provided to the patient including lifestyle modifications and strategies for mental health] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Medication Management: [Medication initiations or changes including drug name, dose, frequency and reason for change] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Psychological Strategies: [Psychological strategies discussed or recommended including modality and techniques such as CBT and relaxation techniques] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Referrals: [Referrals made including the exact recipient such as psychologist, psychiatrist or support services, and the reason for referral] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Safety Plan: [Safety plan for the patient including emergency mental health contacts] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Crisis Plan: [Crisis management plan including steps to take and contacts in the event of a crisis] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) Planned Review In: [Timeframe for planned review] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Consent "Patient provided informed consent for the plan and referrals."