Mental Health Note (custom)

History of Presenting Complaints: - [current issues, reasons for visit, and full history of presenting complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) - [associated symptoms or concerns discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Past Medical & Psychiatric History: - [past psychiatric diagnoses, treatments, and hospitalisations] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) - [current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) - [chronic medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Family History: - [psychiatric illnesses in the family including relationship and condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Social History: [occupation and educational background] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph form.) [substance use including smoking, alcohol, and recreational drugs] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph form.) [available social support and relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph form.) Mental Status Examination: -Appearance: [description of clothing, hygiene, and physical characteristics] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Behaviour: [activity level, engagement, and notable behaviours] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Speech: [rate, volume, clarity, and coherence] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Mood: [patient's reported emotional state] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Affect: [observed emotional expression and congruence with mood] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Thoughts: [thought process and content including any delusions or preoccupations] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Perceptions: [hallucinations or sensory misinterpretations including type and impact] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Cognition: [memory, orientation, attention, and comprehension] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Insight: [awareness and understanding of condition and symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) -Judgement: [decision-making and awareness of consequences] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in full sentences.) Risk Assessment: - [risk factors including suicidality, homicidality, or other safety concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Diagnosis: [formal diagnoses using DSM-5 criteria or relevant clinical tools] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a list.) Treatment Plan: - [investigations or assessments conducted] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) - [medications prescribed or adjusted] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) - [psychotherapy approaches or sessions delivered] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) - [psychosocial interventions, family meetings, or collateral information] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) - [referrals made and follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) Safety Plan: [agreed steps to follow during a crisis or risk situation] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph form.)