Meeting Type: Ward Round
Mental Health Act Status: Section 2
When does Section expire: 03/11/2024
Present: Dr. Emily Carter (Consultant Psychiatrist), Nurse Jones, Patient: John Smith
Diagnosis: F32.1 - Moderate depressive episode
Medications:
- Sertraline 100mg daily
- Lorazepam 1mg as required
History of Presenting Complaints:
- The patient reports low mood, anhedonia, and poor sleep for the past three months. He expresses feelings of hopelessness and worthlessness. He has been experiencing suicidal ideation, but denies any active plans or intent. He reports a loss of appetite and a 10kg weight loss.
- Associated symptoms include fatigue, difficulty concentrating, and social withdrawal.
Past Medical & Psychiatric History:
- Diagnosed with Major Depressive Disorder five years ago. Previous episodes treated with medication and psychotherapy. One previous hospitalisation for a suicide attempt.
- No chronic medical conditions.
Family History:
- Mother has a history of recurrent depression.
Social History:
- Unemployed, previously worked as a teacher. Completed a Master's degree.
- Smokes 10 cigarettes per day.
- Limited social support; lives alone.
Meeting notes:
Dr. Carter reviewed Mr. Smith's progress. Mr. Smith stated, "I still feel down most days, but I'm trying to engage in the activities we discussed." Nurse Jones reported that Mr. Smith has been attending group therapy sessions and is compliant with his medication. Dr. Carter noted that the patient's mood has slightly improved since admission, but suicidal ideation persists. She stated, "We need to closely monitor his risk and adjust his treatment plan as needed." The patient agreed to continue with the current treatment plan.
Mental Status Examination:
- Appearance: Appears his stated age, well-kempt but with a slightly unkempt appearance. Clothing is appropriate for the setting.
- Behaviour: Psychomotor retardation observed. Slow movements and speech.
- Speech: Slow, soft volume, and monosyllabic.
- Mood: Reports feeling "down" and "hopeless."
- Affect: Restricted affect; congruent with reported mood.
- Thoughts: Preoccupied with negative thoughts and feelings of worthlessness. Reports suicidal ideation.
- Perceptions: No hallucinations reported.
- Cognition: Oriented to time, place, and person. Concentration is slightly impaired.
- Insight: Acknowledges having a mental health problem and understands the need for treatment.
- Judgment: Judgment appears impaired due to the severity of his depression.
Risk Assessment:
- Moderate risk of suicide due to persistent suicidal ideation and previous attempt. No current plans or intent.
Diagnosis:
- F32.1 - Moderate depressive episode. Based on DSM-5 criteria, the patient meets the criteria for a moderate depressive episode.
Formulation: The patient's current presentation is likely due to a combination of biological vulnerability, psychosocial stressors, and lack of social support.
Treatment Plan:
- Continue Sertraline 100mg daily.
- Continue Lorazepam 1mg as required for anxiety.
- Increase frequency of individual therapy sessions to twice per week.
- Continue group therapy.
- Review medication in one week.
- Refer to occupational therapy for vocational support.
- Family meeting planned for next week.
- Follow-up appointment in one week.
Safety Plan:
- Contact crisis team if suicidal thoughts worsen.
- Identify coping strategies to manage distress.
- Contact a friend or family member for support.
- Remove access to means of self-harm.
Meeting Type [what kind of a meeting this is, the objective of the meeting]
Mental Health Act Status [either Section 2/Section 3/Section 37/Section 5(2)/Informal or other]
When does Section expire [Section expiration]
Present [who is present in the meeting and their role]
Diagnosis [ICD-11, DSM-V coding]
Medications:
- [List current medications.] (Only include [current medications] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
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.)
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.)
Meeting notes:
- Clearly describe the meeting. Give a high level of detail. Who said what. Give quotes.
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, homicidally, 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.)
Diagnosis:
- [Insert the 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.)
Formulation: -[what has led to current psychiatric presentation]-
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.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 that the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit it completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)
