**IDENTIFICATION:** J.S., [insert age] 28-year-old female. The patient is currently unemployed and lives with her parents. She completed high school and has no further education. She reports being single and has no children. She has lived with her parents for the past 6 months, prior to that she was living in a shared apartment. She is not currently working or attending school.
**REASON FOR REFERRAL:** Suicidality
**CHIEF COMPLAINT:** “I want to die.”
**HISTORY OF PRESENTING ILLNESS:** The patient presents to the emergency department today with acute suicidal ideation. She reports feeling overwhelmed and hopeless, stating she has been experiencing these feelings for the past two weeks. She reports a significant increase in her anxiety and depressive symptoms over the past week. She reports feeling worthless and has been isolating herself from friends and family. She reports difficulty sleeping, with insomnia nearly every night. She denies any changes in appetite. She reports that she has been having thoughts of self-harm, including thoughts of jumping off a bridge. She denies any history of self-harm. She reports that she has been feeling this way since she lost her job two weeks ago. She denies any history of previous psychiatric treatment.
(Situation): The patient was brought to the emergency department by her parents after they found her crying and expressing suicidal thoughts. She had locked herself in her room and refused to come out. The parents called emergency services, who brought her to the hospital for evaluation. She was assessed by the triage nurse and placed on a mental health watch.
(Stressors): The patient reports significant stress related to her recent job loss. She feels she is a failure and is worried about her financial situation. She also reports feeling pressure from her parents to find a new job quickly. She reports that she feels like she is a burden to her family.
(Symptoms):
* Mood: Depressed mood, feelings of hopelessness, worthlessness.
* Anxiety: Increased anxiety, feeling overwhelmed.
* Safety: Suicidal ideation with plan (jumping off a bridge).
(Safety): The patient reports active suicidal ideation with a plan to jump off a bridge. She denies any intent to harm others.
(Substance Use): The patient denies any current use of alcohol, cannabis, stimulants, opioids, or other drugs. She denies any history of substance use.
(Current Supports): The patient is not currently seeing a psychiatrist or therapist. She has no structured support for her mental health.
(Collateral): The patient's parents were present and provided additional information. They confirmed the patient's recent job loss and expressed concern about her mental state. They reported that the patient has been withdrawn and irritable over the past two weeks.
**PAST PSYCHIATRIC HISTORY:**
**MEDICAL HISTORY:**
1. No known medical conditions.
**MEDICATIONS:**
1. None.
**ALLERGIES:** No Known Drug Allergies
**FAMILY HISTORY**: Mother: History of depression. Father: No known psychiatric history.
**BRIEF PSYCHOSOCIAL HISTORY:** The patient was born in London, UK. She has one sibling, a younger brother. She reports a generally positive childhood, but recalls feeling pressure to succeed academically. Her parents are supportive but can be overbearing. She has never experienced physical, emotional, or sexual abuse. She completed high school and has not pursued further education. She has worked in retail for the past five years. She has been in a relationship for two years, but it ended six months ago. The major life event was the loss of her job two weeks ago.
**MENTAL STATUS EXAM (MSE):**
- Appearance: The patient appears dishevelled, with unkempt hair and clothing. She appears her stated age.
- Behaviour: The patient is restless and fidgety, pacing in the room. She is tearful and appears distressed.
- Speech: The patient's speech is normal in rate and volume, but she speaks with a soft tone. Her speech is coherent.
- Mood: The patient reports feeling “sad” and “hopeless.”
- Affect: The patient's affect is congruent with her stated mood. She displays a constricted range of affect.
- Thought Process: The patient's thought process is linear and goal-directed.
- Thought Content: The patient reports suicidal ideation with a plan. She denies any homicidal ideation, delusions, or hallucinations.
- Perceptions: No hallucinations reported.
- Cognition: The patient is alert and oriented to person, place, and time. Her memory appears intact.
- Insight: The patient acknowledges that she is experiencing a mental health crisis.
- Judgment: The patient's judgment appears impaired due to her suicidal ideation.
**IMPRESSION:**
Primary Diagnosis: Major Depressive Disorder, Severe, with Suicidal Ideation.
**PLAN:**
1. **Safety**: The patient is at high risk for suicide and requires immediate intervention. The patient is an indication for psychiatric admission. The patient needs to be certified.
2. **Biological**: Order a comprehensive metabolic panel (CMP), complete blood count (CBC), and urine drug screen (UDS). Start the patient on an antidepressant medication, such as sertraline, and an anxiolytic medication, such as lorazepam, as needed. Consult with the on-call psychiatrist.
3. **Psychosocial**: Refer the patient to a psychiatrist for ongoing care. Refer the patient to a therapist for individual therapy. Encourage the patient to attend support groups. Contact the patient's parents to provide support and education.
“The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.”
(Include all information I describe from other clinicians’ for example their assessments, observations, and impressions as documented in the transcript and context. Do not omit any details from any of the transcript or context. Place all information from myslef and different clinicians information in the appropriate sections of the History of Presenting Illness (HPI) or other relevant areas, such as Situation, Stressors, Symptoms, Safety, Substance Use, or Collateral. If multiple clinicians provide different assessments, document each perspective as stated without interpretation. This ensures a complete and accurate representation of the patient’s condition in acute psychiatric care.)
**IDENTIFICATION:** [State the patient’s initials, age, and describe any other demographic data that could give the reader a sense of where this person is in life including level of education, current employment, relationship status, children, and living arrangements. If available, describe how long the patient has been in their current living arrangement, and where they were before that. If mentioned, described if the patient is doing work or school full-time or part-time, or if they are on leave and for how long.]
**REASON FOR REFERRAL:** [State the reason the physician referred this patient for a psychiatric consult. If no reason can be found, instead include "NOT STATED". An example for this section would be: "Suicidality" ]
**CHIEF COMPLAINT:** [Transcribe the patient's stated reasons for the visit without omission or emphasis in a neutral tone. If no reason was stated, simply state "NOT REPORTED".]
**HISTORY OF PRESENTING ILLNESS:** (You must document this entire section in paragraph form. Be extremely detailed. Clearly document all symptoms (pertinent negatives and pertinent positives), relevant history, and details about current medical symptoms, including duration, severity, and any triggering events. Provide an exceptionally detailed timeline and narrative of the patient's psychiatric symptoms as per the DSM-5. Document any changes in symptoms since the last visit, focusing on the timeline of when the patient began experiencing their current mental health concerns.)
(Situation): [Describe the timeline and key events leading to hospital presentation.] (Provide a detailed, chronological narrative covering the onset of symptoms, precipitating events, emergency medical interventions, hospital transfers, specialist assessments, and procedures performed. Clearly indicate when and in what order events occurred. If mentioned, list any medication trials since the onset of presenting illness, including trial and response. f mentioned, include any significant developments since admission. Write in paragraph form, ensuring clarity and logical progression of events.)
(Stressors): [Outline significant stressors contributing to or worsening the patient’s condition.] (Document relevant external stressors such as financial difficulties, housing instability, work-related pressures, or personal hardships. Ensure that this section ALWAYS remains distinct from the "Situation" section by focusing solely on stressors and their potential impact on the patient’s health, NEVER duplicate information from "Situation" section. Ensure that this section does not list symptoms, UNLESS the symptom is specifically identified as a stressor. Write in paragraph form with clear, structured descriptions.)
(Symptoms): [Describe the recent psychiatric symptoms that the patient has been suffering from. Group together symptoms into the following organization: mood; anxiety; psychosis; mania; personality disorder; trauma related disorder; eating disorder. Include pertinent positives and pertinent negatives. Do not include past historical symptoms. If a symptom grouping is not discussed, say: "NOT REPORTED". Do not list historical diagnoses.]
(Safety): [Document any suicidal ideation (active or passive), suicidal intent, or plan. Document any homicidal ideation (active or passive). Document pertinent positives and negatives. Do not include historical suicide attempts.]
(Substance Use): [Document current use of alcohol, cannabis, stimulants, opioids, and other drugs. Include last time used, as well as pattern of use. Document if they have ever needed treatment for substance use. Do not include historical substance use.]
(Current Supports): [Document if they are currently being seen by a physician for their mental health, if they are currently in therapy or have any structured support for their mental health. Only mention a psychiatrist in this section if it is someone who they are currently seeing on an ongoing basis. Otherwise do not include this section.]
(Collateral): [Identify and incorporate any relevant information obtained from collateral sources such as family members, caregivers, or previous treatment providers. This information is vital for a complete understanding of the patient's mental health history.]
**PAST PSYCHIATRIC HISTORY:**
[document all past psychiatric diagnoses including condition name and date of diagnosis, if known. Do not include psychiatric hospitalizations in this section — reserve these for the hospitalization section below.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as numbered list.)
[describe history of self-harm behaviours including age of onset and nature of behaviours. Do not include details related to psychiatric admissions — reserve these for the hospitalization section below.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as numbered list.)
[record suicidal ideation or suicide attempts not leading to hospitalization. If a suicide attempt resulted in a hospital admission, include only in the hospitalization section below.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as numbered list.)
[list notable psychiatric-related incidents that did not result in hospitalization, such as online posts, disclosures to others, emergency services involvement etc. Do not include incidents that led to hospital admission — these should be included in the hospitalization section below.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as numbered list.)
**Past psychiatric hospitalizations:**
[for each discrete hospitalization event, provide a cohesive paragraph that includes: the date or date range of the event; what precipitated the admission (e.g. overdose, suicidal behaviour); the duration of admission; the facility/location of care; the attending physician (if known); the diagnosis at admission (if stated); a brief summary of presenting symptoms; the assessment outcomes; and any discharge plans or follow-up recommendations if documented. If multiple dates are close together (e.g. overdose, assessment, admission), these should be combined into a single paragraph under one date range. If hospitalizations are years apart, start a new paragraph for each. Begin each paragraph with the date or date range in bold.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format, one paragraph per hospitalization. Put the date range in italics.)
**MEDICAL HISTORY:**
1. [medical history] (Provide a numbered list of all past and current medical conditions explicitly mentioned in the transcript, contextual notes, or clinical note. Include chronic illnesses, acute conditions, past surgeries, and any significant medical events. Document all past and current treatments, including medical procedures and any previous or ongoing management plans. If specific dates are provided, include them alongside each condition or treatment to ensure chronological accuracy. Ensure clarity by using a structured format.)
**MEDICATIONS:** [Provide a NUMBERED list of CURRENT medications, dosages. If available, in parentheses include if patient was not taking that medication or if it was held on admission.]
**ALLERGIES:** [Document listed allergies or adverse reactions to medications that were mentioned. If none mentioned, simply state "No Known Drug Allergies".]
**FAMILY HISTORY**: [In list format, list all family psychiatric histories and diagnoses mentioned.]
**BRIEF PSYCHOSOCIAL HISTORY:** [Document where the patient was born, if the patient has siblings, what growing up was like, what the patient’s parents are like, any physical, emotional, or sexual abuse experienced, educational history, occupational history, romantic history, and any major life events discussed. Document this section in paragraph form.]
**MENTAL STATUS EXAM (MSE):**
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics(include only if applicable).]
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors(include only if applicable).]
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech (include only if applicable).]
- Mood: [Record the patient's self-described emotional state, using their own words if possible (include only if applicable).]
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood (include only if applicable).]
- Thought Process: [Assess the patient's thought process, noting circumstantiality, tangentiality, etc. (include only if applicable)]
- Thought Content: [Assess the patient's thought content, noting any suicidality, homicidal thoughts, delusions, or preoccupations (include only if applicable).]
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient (include only if applicable).]
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension (include only if applicable).]
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial (include only if applicable).]
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions (include only if applicable).]
**IMPRESSION:**
(Your task for this section is to ensure a thorough and accurate portrayal of the patient's mental health status, capturing all relevant clinical information for an informed diagnosis and assessment)
Primary Diagnosis: [Based on the transcript, provide a professional analysis of the patient's mental health condition that explains their reason for referral. Include differential diagnoses where applicable. Ensure that the diagnosis is supported by evidence from the patient's symptoms, history, diagnostic results, and session observations. ]
Secondary Diagnoses: [Based on the transcript, provide any additional diagnosis that explain other symptoms that are not captured by the primary diagnosis. Include diagnoses stated under 'Past Psychiatry History', but label them as 'History of…". ]
**PLAN:**
(Your task in this section is to outline the management and treatment plan discussed during the visit, including medications, therapy, referrals, or any other interventions planned. Include all after care instructions that were mentioned in the transcript. Be clear and ensure the patient instructions are extracted from the transcript)
1. **Safety**: [Describe whether there is acute suicidality or homicidality. Indicate whether the patient is an indication for psychiatric admission. Mention if the patient needs to be certified. ]
2. **Biological**: [Describe any investigations that need to be ordered. Describe any medications that need to be ordered. Describe any other medical specialties that need to be consulted]
3. **Psychosocial**: [Describe any allied health services that need to be consulted. Describe any collateral that needs to be obtained. Describe any letters that need to be written for the patient. Describe any community services that the patient needs to be referred to. Describe any psychotherapy modalities that would be beneficial for the patient.]
“The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.”
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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 the information has not been explicitly mentioned in your output, just omit the placeholder completely if not mentioned.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information) (always bold section headings, this is very important)
