Behavior Template

Problem List: 1. [List of medical issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: 1. [List of medications and doses, including instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Discontinued Medications: - [List of medications discontinued with reasons for stopping] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Support Team: - [List of involved supports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) School: [Education setting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Grade: [School year] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Presenting Complaints: [Main concerns for the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I had the pleasure of reviewing [the patient] who is now [age in years and months] on [Date of review]. The patient attended with [caregiver], who is the [relationship to patient]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) School Progress: [Summary of the patient's school progress and challenges] (Comment on efficacy of stimulant medication throughout the school day where applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on any behavioural challenges, suspensions, aggression, or anxiety at school if applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on any learning supports being received if applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Use “the patient” and “caregiver(s)” to identify who said what or who observed what in the consult; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Home Progress: [Summary of the patient's home life and relevant issues] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Use “the patient” and “caregiver(s)” to identify who said what or who observed what in the consult; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on any aggression or anxiety if applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on ability to complete homework in the afternoon or extracurricular activities if applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on caregiver stress if applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allied therapies and External supports: [Summary of allied therapies and external supports] (Comment on use of allied therapists including physiotherapy, occupational therapy, speech pathology, dietetics, psychology where applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Comment on frequency of visits and goals of therapy; avoid identifiable names of providers or organizations; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mood and Mental Health: [Assessment of the patient's mood and mental health] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Use “the patient” and “caregiver(s)” to identify who said what or who observed what in the consult; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Where applicable; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Confidential Adolescent Psychosocial History: Home: [Who is at home and whether the patient feels safe at home] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Education: [Current grade, any issues at school, bullying, fighting, academic performance] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Activities: [Hobbies, activities for fun or in spare time, employment, volunteering] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Drugs: [Smoking, vaping, drug use, alcohol use] (Include discussion of smoking, vaping, drugs, and alcohol use only here and no other section of the note; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Sexuality and Gender: [Gender identity and pronouns, sexual orientation, sexual history] (Include any discussion of condom use and contraception here; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mental Health: [Depression, anxiety, thoughts of suicide, thoughts of self-harm, or suicidal ideation] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Sleep and Diet: [Assessment of the patient's sleep patterns and dietary habits] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Use “the patient” and “caregiver(s)” to identify who said what or who observed what in the consult; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Side Effects of Medications: [Report on any side effects experienced by the patient] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Use “the patient” and “caregiver(s)” to identify who said what or who observed what in the consult; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Do not write each point as a list; write information as a paragraph; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: Weight – [Weight in kg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Height – [Height in cm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) BMI – [BMI in kg/m2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) BP - [BP in mmHg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mental status examination findings, including appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of physical examination findings] (Write in full sentences in paragraphs; Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Developmental screening, behavioural questionnaires, scores, and interpretation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary: [Summary of the patient's current condition and diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - [Outline of the treatment plan, including any medication adjustments and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)