Nicola Lodge phone followup

"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." Psychiatry Progress Note: Date of Review: 1 November 2024 Time of Review: 10:00 AM Patient Name: John Smith Date of Birth: 01/01/1940 Medical Record Number: 1234567 Location: Maplewood Nursing Home Reviewed with: Nurse Jane Doe, Social Worker Bill Jones Reason for Review: Follow-up on medication management and assessment of recent behavioral changes. Review of Pertinent Clinical Information (from nursing/care providers): - Behavioral Observations: Increased agitation and verbal outbursts in the past week, particularly during mealtimes. Refusal to participate in group activities. - Mood and Affect: Patient appears anxious and irritable. Affect is constricted. - Cognition: Some decline in short-term memory noted. Orientated to person, place, and time, but with some difficulty. - Sleep Patterns: Difficulty falling asleep, reports of early morning awakenings. - Appetite and Nutritional Intake: Decreased appetite, weight loss of 3 pounds in the last month. - Activities of Daily Living (ADLs) and Functional Status: Requires assistance with dressing and bathing. - Social Interaction: Socially withdrawn, avoids interactions with other residents. - Physical Health Concerns: Reports of mild chest pain, no new physical health concerns. - Medication Adherence and Side Effects: Adherent to medications. No reported side effects. - Staff Concerns/Questions: Concerns about increased agitation and potential for falls. Chart Review: - Current Medications: Sertraline 100mg daily, Risperidone 1mg at bedtime, Lorazepam 0.5mg as needed for anxiety. - Past Psychiatric History: History of major depressive disorder, anxiety disorder, and dementia. Previous hospitalizations for depression. - Relevant Medical History: Hypertension, type 2 diabetes, and osteoarthritis. - Recent Lab Results/Diagnostics: Recent blood work within normal limits. No recent imaging. - Previous Psychiatric Recommendations: Continue current medication regimen, encourage participation in activities, and monitor for changes in behavior. Recommendations: - Medication Adjustments: Increase Sertraline to 150mg daily. Consider increasing Risperidone to 1.5mg at bedtime if agitation persists. - Behavioral Interventions: Implement a consistent daily routine, provide structured activities, and utilise de-escalation techniques during episodes of agitation. - Follow-up Plan: Schedule a follow-up review in two weeks to assess response to medication adjustments and behavioral interventions. - Staff Education/Guidance: Educate staff on recognising signs of agitation and implementing de-escalation strategies. Provide training on managing anxiety in patients with dementia. - Further Investigations: No further investigations are needed at this time. - Communication with Family/Guardians: Contact the patient's daughter to discuss the changes in behaviour and medication adjustments. "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. Emily Carter "Geriatric Psychiatrist "