Psychiatrist to GP Letter

Thank you for referring [the patient’s first name] to see me. [document patient demographics including age, gender, and other relevant details. Include housing arrangements, relationship status, and employment details or pension information.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the patient's presenting issues, reasons for visit, and any relevant context. Include in this section all the information about the predominant mental health subject mentioned in the transcript. Document all the symptoms and triggers if appropriate. Also document the duration of these conditions, e.g., longstanding, 5-year history, etc. If there is more than one predominant condition, write the information in individual paragraphs for each condition. Include details of previous treatments, treating doctors, and admissions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the patient's mood, including any relevant observations or patient-reported information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document any symptoms or history of psychosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe any symptoms or history of anxiety] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document any symptoms or history of eating disorders] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe any symptoms or history of ADHD] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document any symptoms or history of Autism Spectrum Disorder (ASD). Describe any symptoms of social communication difficulties, such as: difficulties in social-emotional reciprocity including trouble with social approach, back-and-forth conversation, sharing interests with others, and expressing/understanding emotions; difficulties in nonverbal communication used for social interaction, including abnormal eye contact and body language, and difficulty understanding the use of nonverbal communication like facial expressions or gestures for communication; deficits in developing and maintaining relationships with others (outside of caregivers), including lack of interest in others, difficulty responding to different social contexts, and difficulty in sharing imaginative play. Detail behavioural symptoms such as stereotyped speech, repetitive motor movements, echolalia (repeating words or phrases), and repetitive use of objects or abnormal phrases; rigid adherence to routines, ritualised behaviours, and extreme resistance to change; highly restricted interests with abnormal intensity or focus; and increased or decreased reactivity to sensory input or unusual interest in sensory aspects of the environment.] Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Omit this paragraph if already covered earlier.) [document the patient's past psychiatric history, including previous diagnoses and treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Omit this paragraph if the information is already included in previous paragraphs.) [describe any family history of psychiatric conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [provide very detailed description of the patient's history of alcohol use. Include information about the time of onset, the pattern of drinking, changes to drinking patterns, the volume of alcohol use, and any history of withdrawal seizures or delirium tremens. Detail previous treatment, counselling, AA attendance, or admissions for detoxification or rehabilitation.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Omit this paragraph if the information is already included above.) [provide any details of the patient’s history of drug use, cigarette use, and gambling disorder, including instances of lying related to gambling or chasing losses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in one paragraph of full sentences.) [document the patient's past medical history, including any relevant conditions or surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in one paragraph of full sentences.) [document any contraindications for medications, including family history of specific conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document any relevant forensic history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document any known allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [the patient’s first name] is currently prescribed the following medication: [document current medications, including dosages and any over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences or list medications in dot points.) [document family history and dynamics, relevant childhood issues, education history, employment history, and relationship history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a large, detailed paragraph of around 150 words.) [document the patient's appearance, behaviour, speech, mood, affect, thought form, thought content, presence of delusions or hallucinations or other psychotic phenomena. Provide information about insight, judgement, or cognitions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief paragraph of full sentences.) So, in summary, my impression is [the patient’s first name] suffers from [document the patient's primary diagnosis] associated with [document other diagnoses of mental illnesses]. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a short paragraph of full sentences.) My management for [the patient’s first name]: [document the patient's treatment plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write the plan in a paragraph explaining my intentions for further investigations, medications, clarification of diagnosis, gaining collateral history, reviewing school records, or using questionnaires such as DIVA 5, DASS, etc.) Thank you once again for referring [the patient’s first name] to see me. I will keep you informed of [his/her] progress. (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Write this as a letter of up to 500 words.)