"The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks."
**IDENTIFYING DATA**
Mr. John Smith, [insert age] 82-year-old male, residing in a long-term care facility. He is widowed and retired. His financial situation is stable, supported by a pension and savings.
**Referral source:** Dr. Emily Carter, Family Physician.
PHN: 123-456-789
**INTERIM HISTORY**
Patient presents with increased confusion and agitation over the past week. He reports difficulty remembering recent events and struggles with word-finding. He denies any new physical symptoms. His mood appears labile, with periods of both sadness and irritability. Sleep patterns are disrupted, with frequent nighttime awakenings. Eating habits are unchanged. No recent medication changes. No new side effects reported.
**COLLATERAL INFORMATION: **
Mrs. Jane Doe, daughter, reports increased confusion and agitation, especially in the evenings. She notes he has been wandering more frequently and has become more resistant to care.
Mr. Robert Green, Nurse, reports increased confusion and agitation, especially in the evenings. He notes he has been wandering more frequently and has become more resistant to care.
**CURRENT MEDICATIONS**
- Donepezil 10mg daily, for Alzheimer's disease.
- Sertraline 50mg daily, for depression.
- Lorazepam 0.5mg as needed for anxiety.
**Mental Status Examination: **
Appearance: The patient is well-groomed and appropriately dressed. He appears his stated age.
Behavior: The patient is restless and agitated, pacing during the interview. He is cooperative but easily distracted.
Speech: Speech is clear but slow, with occasional word-finding difficulties. The patient is coherent.
Mood: The patient reports feeling sad and frustrated with his memory loss.
Affect: Affect is congruent with mood, with periods of tearfulness and irritability.
Thoughts: The patient denies any suicidal ideation, homicidal ideation, or delusions. He expresses concern about his memory.
Perceptions: patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations.
Cognition: The patient is oriented to person but not to time or place. He has significant deficits in recent and remote memory. Concentration is impaired. He is able to follow simple commands.
Insight: The patient acknowledges his memory problems but does not fully understand the extent of his cognitive impairment.
Judgment: Judgment is impaired due to cognitive deficits.
**INVESTIGATIONS**
No new investigations reviewed since the last follow-up.
**IMPRESSION**
82-year-old male with a history of Alzheimer's disease, presenting with increased confusion, agitation, and functional decline. He exhibits temporal disorientation, repetitive questioning, and recent recall deficits. He uses a walker for mobility and is at risk for falls. He is oriented to person but not to time or place. His mood is labile, and he has no other symptoms. He receives support from family and staff, with safety measures in place.
**Plan: (Always ensure that under each subheading below it is filled with bullet points, If a subheading below is omitted re-number the subsequent subheading sections)**
**1. Certification**
No certification is indicated at this time.
**2. Safety**
• The patient is at risk for falls due to his cognitive impairment and mobility issues. The facility is implementing fall prevention strategies.
• There is no current suicidal or homicidal ideation.
• Aggression Verbal / Physical: Please continue regular ABC assessments following behavioural events so that a comprehensive behavioural plan can be developed for his care management. The detailed documentation as obtained is extremely helpful in helping delineate and identify strategies that can be discussed. -→Suggest team debriefs and re-evaluation of PIECES care huddles following any physical aggression events.
**3. Biological (including Medications)**
• Continue Donepezil 10mg daily.
• Continue Sertraline 50mg daily.
• Consider increasing Lorazepam to 1mg as needed for agitation.
• I have reviewed today with family’s the risk and benefits of initiating an antipsychotic in the context of a known major neurocognitive disorder. Including the black box warning for increased cerebrovascular and all cause mortality. Family agree that at this point the benefits outweigh the risk. I have also reviewed other common side effects.
**4. Share-care/ Investigations**
• A number investigations should be monitored on a regular basis given the plan at this time to use of psychotropic agents. We will ask family physician to assist this this.
• We will recommend monitoring of: CBC Electrolytes, BUN, Creatinine, TSH, INR, PTT, AST, ALT, GGT, Alk Phos, Bilirubin, VIt B12, Folate, HgB A1C, lipid panel, and EKG on a routine basis.
**5. Neurostimulation**
Not indicated at this time.
**6. Psychosocial**
• I encouraged the facility to continue to have regular in open cleared dialogue with the family to provide education on the BPSD symptoms as observed.
• Writer has reviewed with staff the importance of ensuring consistent but flexible care approach.
**7. Follow-up**
• Follow-up will be organized and arranged with the director of care
"It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. "
Dr. Thomas Kelly
"Geriatric Psychiatrist "
Date: 1 November 2024
"The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks."
**IDENTIFYING DATA**
[describe the patient's demographic information, living situation, marital status, age, gender, occupation, retirement status, financial situation, and any other relevant personal details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Referral source:** [document the source of referral for the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
PHN: [document the patient's Personal Health Number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**INTERIM HISTORY**
[describe the patient's presenting concerns, current symptoms, history of presenting complaints, cognitive function, memory, episodes of confusion, anxiety related to memory, frustration with memory lapses, mood, enjoyment of activities, sleep patterns, eating habits, recent medication changes, and any new side effects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**COLLATERAL INFORMATION: **
[Always include collateral information provided, provide names or roles of individuals who provided collateral information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Always include collateral information provided, provide names, collateral information provided by each individual, with each individual's information in a separate paragraph] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[document information provided by collateral sources, including details about the patient's confusion, use of assistive devices, near-falls, repetitive questioning, incidents of wandering, safety monitoring, and any new health issues observed by collateral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**CURRENT MEDICATIONS**
- [list all current medications, including dosage and frequency, and the reason for taking each medication] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Mental Status Examination: **(ALWAYS write Mental Status Examination in paragraphs of full sentences. NEVER bullet point or list, unless instructed otherwise.)
[Appearance: patient's clothing, hygiene, and any notable physical characteristics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Behaviour: patient's activity level, interaction with their surroundings, and any unique or notable behaviors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Speech: rate, volume, clarity, and coherence of the patient's speech] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Mood: patient's self-described emotional state, using their own words if possible] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Affect: range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Thoughts: patient's thought process and content, noting any distortions, delusions, or preoccupations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Perceptions: any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient] [if patient denied AH/VH and there are no perceptual disturbances mentioned by the physician then state -- patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations. ] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Cognition: patient's memory, orientation to time/place/person, concentration, and comprehension] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Insight: patient's understanding of their own condition and symptoms, noting any lack of awareness or denial] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Judgment: patient's decision-making ability and understanding of the consequences of their actions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(ALWAYS write Mental Status Examination in paragraphs of full sentences. NEVER bullet point or list, unless instructed otherwise.)
**INVESTIGATIONS**
[document any new investigations reviewed since the last follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**IMPRESSION**
[summarize the patient's age, gender, history of cognitive impairment, current management, ongoing memory deficits (e.g., temporal disorientation, repetitive questioning, recent recall), functional concerns (e.g., walker use, fall risk), orientation status, preserved cognitive functions (attention, insight), general mood, presence/absence of other symptoms (psychosis, mood disorder, neurological symptoms), and the level of support from family and staff including safety measures in place] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Plan: (Always ensure that under each subheading below it is filled with bullet points, If a subheading below is omitted re-number the subsequent subheading sections)**
**1. Certification**
[document if any certification, such as for driving or legal capacity, is indicated at the current time.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**2. Safety**
[document any current safety concerns for the patient, including their living environment, and the presence or absence of suicidal or homicidal ideation.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
• Aggression Verbal / Physical: Please continue regular ABC assessments following behavioural events so that a comprehensive behavioural plan can be developed for his care management. The detailed documentation as obtained is extremely helpful in helping delineate and identify strategies that can be discussed. -→Suggest team debriefs and re-evaluation of PIECES care huddles following any physical aggression events. "
**3. Biological (including Medications)**
[document the plan for managing the patient's biological aspects, including continuation of current medications, strategies for medication management, and monitoring of nutritional status and weight.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(If an antipsychotic is being recommended the include the following --I have reviewed today with family’s the risk and benefits of initiating an antipsychotic in the context of a known major neurocognitive disorder. Including the black box warning for increased cerebrovascular and all cause mortality. Family agree that at this point the benefits outweigh the risk. I have also reviewed other common side effects.)
**4. Share-care/ Investigations**
[document the plan for communicating findings and recommendations with other healthcare providers or family members involved in the patient's care. Document any interventions or requests for share-care to follow-up on such as pain management, constipation management, other medical issues...] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
"• A number investigations should be monitored on a regular basis given the plan at this time to use of psychotropic agents. We will ask family physician to assist this this."
"• We will recommend monitoring of: CBC Electrolytes, BUN, Creatinine, TSH, INR, PTT, AST, ALT, GGT, Alk Phos, Bilirubin, VIt B12, Folate, HgB A1C, lipid panel, and EKG on a routine basis."
**5. Neurostimulation**
[document if neurostimulation is indicated as part of the patient's treatment plan.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**6. Psychosocial**
[document the psychosocial interventions, including encouragement of cognitively stimulating activities, support for family involvement, and consideration of referrals to other services like occupational therapy for functional assessment.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
"• I encouraged the facility to continue to have regular in open cleared dialogue with the family to provide education on the BPSD symptoms as observed. "
"• Writer has reviewed with staff the importance of ensuring consistent but flexible care approach."
**7. Follow-up**
"Follow-up will be organized and arranged with the director of care"
"It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. "
Dr. [Psychiatrist's Name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
"Geriatric Psychiatrist "
(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. Ensure the note is detailed and comprehensive)
