New Patient Note

**Identifying Information** [Insert Identifying Information] ([Identifying Information includes Name, age, list of diagnoses and anything from social history that identifies the patient, such as who they live with, where they live, pets, things that make the person stand out. Use sentence format) **ASSESSMENT** **General Assessment** [draft an assessment by describing diagnosis or differential diagnosis, key features supporting diagnosis, biopsychosocial factors that contribute to vulnerabilities, stressors or events that impact current presentation, biopsychosocial factors that are protective, potential obstacles or barriers that could impact treatment or recovery, priority areas for treatment] (Only include details if explicitly discussed in the transcript. Use complete sentences, formal structure, moderate details) **Nicotine Assessment** [Insert details about nicotine use and plans for nicotine use] (Include details if explicitly discussed, otherwise use data from contextual notes and indicate details are from prior encounter) **Risk Assessment** Pt is at chronically elevated risk of harm to self or others based on: [insert risks for harm to self or others, including but not limited to prior psychiatric hospitalizations, psychiatric diagnosis, history of suicide attempt, current suicidal thinking, history of violence, history of incarceration, history of substance use] (only include details discussed in transcript, otherwise leave blank). These risks are mitigated by: [insert protective factors, including but not limited to denial of suicidal/homicidal thoughts, plans or intent, willingness and motivation for treatment, future oriented thinking, sense of responsibility to family, stable housing, stable employment, family support, denies access to guns] (only include details discussed in transcript, otherwise leave blank) **Diagnoses** - [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.) **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] (Use list form, write in this format: CONTINUE, INCREASE, DECREASE or STOP, Medication name, dosage and frequency (start date, inc or dec date). Include medication plans explicitly stated in 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.) **REPORTED HISTORY** **Past Medical History** - [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.) **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.) **Past Psychiatric History** - Psychiatric Diagnoses: [Describe past psychiatric diagnoses] (Only include [past psychiatric diagnoses] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Psychiatric Hospitalizations: [Describe past psychiatric hospitalizations] (Only include [past psychiatric hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Outpatient treatment: [Describe outpatient mental health treatment] (Only include [past psychiatric hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Suicide Attempts: [Describe suicide attempts] (Only include [suicide attempts] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Self Harm: [Describe self harm] (Only include [self harm] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **Family History** - Family Psychiatric Diagnoses: [Describe family psychiatric diagnoses] (Only include [family psychiatric diagnoses] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Family Psychiatric Hospitalizations: [Family Psychiatric Hospitalizations] (Only include [Family Psychiatric Hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Family Completed Suicide: [Family Completed Suicide] (Only include [Family Completed Suicide] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Family Substance Use: [Family Substance Use] (Only include [Substance Use] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **Social History** - Living Situation: [Living situation] (Only include [living situation] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Relationship Status: [Relationship status] (Only include [relationship status] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Children: [Children] (Only include [children] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - School: [School] (Only include [School] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Income: [Income] (Only include [income] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Abuse, Neglect, Trauma: [Abuse, Neglect, Trauma] (Only include [abuse, neglect, trauma] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Domestic Violence: [Domestic Violence] (Only include [domestic violence] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Legal History: [Legal History] (Only include [legal history] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Access to weapons: [Access to guns] (Only include [access to guns] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) **Substance Use History** **Treatment** - Residential Treatment for Substance Use: [residential substance use treatment] (Only include [residential substance use treatment] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) - Outpatient Treatment for Substance Use: [outpatient substance use treatment] (Only include [outpatient substance use treatment] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise state not discussed.) **Substance Use** - Opioids: [Opioids] (Only include [opioids] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Benzodiazepines: [Benzodiazepines] (Only include [benzodiazepines] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Cocaine: [Cocaine] (Only include [cocaine] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Methamphetamine: [methamphetamine] (Only include [methamphetamine] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Prescribed Stimulants: [prescribed stimulants] (Only include [prescribed stimulants] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Alcohol: [alcohol] (Only include [alcohol] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Marijuana: [Marijuana] (Only include [marijuana] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Nicotine: [Nicotine] (Only include [nicotine] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) - Other: [Other things to get high or intoxicated] (Only include [Other things to get high or intoxicated] if it has been explicitly mentioned in the transcript, contextual notes, or clinical notes, otherwise state not discussed.) **SUBJECTIVE** **HPI** [Describe current issues and reasons for visit.] (Use minimal detail, only include what was explicitly mentioned in the transcript, contextual notes, or clinical note) **Review of Systems** [describe review of systems] (only include what was explicitly mentioned in the transcript, contextual notes, or clinical note) **OBJECTIVE** **Physical Exam** General: NAD MSK: no abnormal movements, no tics/tremors Pulm: no increased work of breathing **Mental Status Examination** APPEARANCE: appropriately groomed, casually dressed, appears stated age BEHAVIOR: Appropriate eye contact, facial expressions and posture. No psychomotor activation or retardation COGNITION: alert, able to attend to conversation FUND OF KNOWLEDGE: average for age/education on gross exam, no formal testing done ATTITUDE: calm, cooperative, communicative SPEECH: normal rate, rhythm, volume LANGUAGE: fluent English with no gross signs of dysarthria MOOD: AFFECT: THOUGHT PROCESS: coherent, linear, goal oriented. No derailment, flight of ideas, perseverance THOUGHT CONTENT: no suicidal/homicidal thoughts, plans or intentions. No apparent delusions, ideas of reference, phobias, or preoccupations PERCEPTIONS: no overt hallucinations or illusions INSIGHT: intact JUDGEMENT: intact (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.)