New Psychiatric Assessment

History of Presenting Complaints: - [Describe current issues with all available details, reasons for visit, and complete history of presenting complaints.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Describe any other associated symptoms with details.] (Only include [associated symptoms with details] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Past Medical & Psychiatric History: - [Describe past psychiatric diagnoses, treatments, hospitalizations.] (Only include [past psychiatric diagnoses, treatments, hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [List chronic medical conditions.] (Only include [chronic medical conditions] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Medications: - [List current medications and allergies.] (Only include [current medications and allergies] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Family History: - [Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses.] (Only include [psychiatric illnesses within the family] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Social History: - [Occupation, level of education.] (Only include [occupation and level of education] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Substance use such as smoking, alcohol, recreational drugs.] (Only include [substance use such as smoking, alcohol, recreational drugs] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Social support.] (Only include [social support] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Mental Status Examination: - Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics.] (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors.] (Only include behaviour details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Speech: [Note the rate, volume, clarity, and coherence of the patient's speech.] (Only include speech characteristics if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Mood: [Record the patient's self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include [emotional response] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include thought process and content if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient.] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension.] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Risk Assessment: - [Assessment of suicidality, homicidality, and other risks.] (Only include [Assessment of suicidality, homicidality, other risks] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Discussion: - [Insert explanation about treatment options and responses by patient.] (Only include [what is said about treatment options, medications, therapy, social support and patient responses] explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Summary: - [Insert the brief summary from transcript including diagnosis, relevant DSM-5 criteria, psychological scales/questionnaires.] (Only include diagnosis details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Treatment Plan: - [Planned investigations.] (Only include [investigations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans.] (Only include medication plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Psychotherapy plans and strategies.] (Only include psychotherapy plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Planned family meetings & collateral information, psychosocial interventions.] (Only include family meetings and psychosocial interventions if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Follow-up appointments and referrals.] (Only include follow-up plans and referrals if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Safety Plan: - [Detail safety plan including steps to take in crisis.] (Only include safety plan details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)