Psychiatry Follow Up

Clinical Update: [summarise the clinical encounter including the patient’s reported struggles, symptoms, medication use and effects, sleep, self-care, social engagement, substance use, mood and anxiety symptoms, and any screening results for other psychiatric conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Mental Status Exam: [document the patient’s mental status covering alertness, cooperation, mood, affect, thought process and content, speech, perceptual disturbances, cognitive function, insight and judgment, and suicidal ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Diagnostic Impression: [record current diagnoses and any differential diagnoses. Include reasoning for primary diagnosis if noted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Medication Recommendations: [describe any medication changes, additions, discontinuations or dosage adjustments, including instructions if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Additional Treatment Recommendations: [document any further clinical recommendations such as referrals, assessments, therapy suggestions or other interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Safety Planning: [outline any safety measures discussed including suicidal risk management, crisis planning or escalation protocols] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Lifestyle and Self-Care: [record any suggestions provided regarding lifestyle changes, routines, coping strategies or wellness planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Patient Understanding and Agreement: [comment on patient’s level of understanding, questions asked, and agreement or disagreement with the proposed treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Follow-Up: [record follow-up appointment details including timeframe, date, time, and format (in-person, telehealth, etc)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)