Meeting Type: Initial Assessment
Mental Health Act Status: Informal
When does Section expire: N/A
Present: Dr. Emily Carter (Psychiatrist), John Smith (Patient)
Diagnosis: F32.1 - Moderate depressive episode
Medications:
- Sertraline 100mg daily
- Lorazepam 1mg as needed for anxiety
Background to Admission:
- The patient, [insert age] John Smith, presents today for an initial psychiatric assessment. He reports feeling increasingly sad and hopeless over the past six months, with a significant loss of interest in activities he previously enjoyed. He reports difficulty sleeping, changes in appetite, and feelings of worthlessness. He denies any suicidal ideation or plans at this time.
- Associated symptoms include fatigue, difficulty concentrating, and social withdrawal.
Past Medical & Psychiatric History:
- Previously diagnosed with major depressive disorder. Treated with Sertraline in the past with some improvement. No previous hospitalizations.
- Chronic medical conditions: Hypertension, managed with medication.
Family History:
- Mother has a history of depression, currently managed with medication.
Social History:
- Occupation: Accountant.
- Level of education: Bachelor's degree.
- Substance use: Occasional alcohol use, denies recreational drug use, smokes 5 cigarettes per day.
- Social support: Lives alone, has a close relationship with his sister.
Meeting notes: Dr. Carter initiated the meeting by introducing herself and explaining the purpose of the assessment. John Smith was cooperative and forthcoming with information. He described his symptoms in detail, including the onset, duration, and severity. He stated, "I just don't feel like myself anymore." He also discussed his current stressors, including work-related pressures and financial concerns. Dr. Carter asked about his support system and coping mechanisms. The patient stated that he has been isolating himself from friends and family.
Mental Status Examination:
- Appearance: Well-groomed, dressed in clean casual clothing.
- Behaviour: Appears slightly slowed, with decreased psychomotor activity.
- Speech: Normal rate and volume, clear articulation, coherent.
- Mood: Subjectively reports feeling sad and hopeless.
- Affect: Restricted, with a blunted range of emotional expression.
- Thoughts: No evidence of psychosis. No suicidal or homicidal ideation.
- Perceptions: No hallucinations or delusions reported.
- Cognition: Oriented to person, place, and time. Intact memory and concentration.
- Insight: Demonstrates some insight into his condition, recognising that he is experiencing symptoms of depression.
- Judgment: Appears to have good judgment.
Risk Assessment: No current risk of harm to self or others.
Diagnosis: F32.1 - Moderate depressive episode. Based on DSM-5 criteria, the patient meets the criteria for a moderate depressive episode.
Formulation: The patient's current presentation appears to be related to a combination of biological vulnerability, work-related stressors, and social isolation.
Treatment Plan:
- Planned investigations: None at this time.
- Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans: Continue Sertraline 100mg daily. Prescribe Lorazepam 1mg as needed for anxiety. Review medication in 2 weeks.
- Psychotherapy plans and strategies: Recommend individual therapy with a focus on cognitive-behavioural techniques.
- Planned family meetings & collateral information, psychosocial interventions: Encourage patient to involve his sister in his care.
- Follow-up appointments and referrals: Schedule a follow-up appointment in two weeks. Refer to a therapist for individual therapy.
- Leave on the ward: N/A
Safety Plan: Patient to contact his sister or the crisis line if he experiences worsening symptoms or suicidal thoughts.
(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.)
Meeting Type (what kind of a meeting this is, the objective of the meeting) Mental Health Act Status (either Section 2/Section 3/Section 37/Section 5(2)/Informal or other) When does Section expire (Section expiration) Present (who is present in the meeting and their role) Diagnosis (ICD-11, DSM-V coding)
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.)
Background to Admission:
- [Describe issues with all available details, reasons for admission, and complete history of presenting complaints. What led to admission.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Describe any other associated symptoms that led to admission with details.] (Only include [associated symptoms with details] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past Medical & Psychiatric History:
- [Describe past psychiatric diagnoses, treatments, hospitalizations.] (Only include [past psychiatric diagnoses, treatments, hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [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.)
Family History:
- [Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses.] (Only include [psychiatric illnesses within the family] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Social History:
- [Occupation, level of education.] (Only include [occupation and level of education] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Substance use such as smoking, alcohol, recreational drugs.] (Only include [substance use such as smoking, alcohol, recreational drugs] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Social support.] (Only include [social support] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Meeting notes: - Clearly describe the meeting. Give a high level of detail. Who said what. Give quotes. (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics.] (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors.] (Only include behaviour details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech.] (Only include speech characteristics if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Mood: [Record the patient's self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include [emotional response] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include thought process and content if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient.] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension.] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Risk Assessment: - [Assessment of suicidality, homicidally, and other risks.] (Only include [Assessment of suicidality, homicidality, other risks] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnosis: - [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.)
Formulation: -[what has led to current psychiatric presentation](Only include diagnosis details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Treatment 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 including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans.] (Only include medication plans if it has been explicitly mentioned in the 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, do not generate your own.)
-[Leave on the ward] (Only include leave status if mentioned in the transcript or background notes. Please include whether leave is escorted or unescorted and the duration and frequency of the leave.)
Safety Plan: - [Detail safety plan including steps to take in crisis.]
(Only include safety plan details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely, do not generate your own.)
(Do not generate your own plan or clinical management, use information from transcript and context provided)
