Clinical Review APARC 01/11/2024
Attended by:
Dr. Eleanor Vance (Consultant Psychiatrist), Sarah Jones (Registered Mental Health Nurse), and David Lee (Social Worker).
This week working on:
* Managing distressing auditory hallucinations.
* Developing coping strategies for anxiety in social situations.
* Exploring the impact of past trauma on current relationships.
Improvements noted:
* Patient reports a decrease in the frequency and intensity of auditory hallucinations. "The voices are quieter now," she stated.
* Patient is attending group therapy sessions regularly and actively participating.
* Patient is demonstrating improved emotional regulation during individual therapy sessions.
Ongoing challenges:
* Persistent feelings of social isolation.
* Difficulty with sleep hygiene.
* Occasional suicidal ideation, though without intent or plan.
Main personal supports in the community:
* Mother, Susan Miller.
* Sister, Emily Carter.
Transition meeting:
Planned for next week.
Any concerns related to medications:
* Patient reports some drowsiness with current medication regimen.
* Patient is compliant with medication.
Further information regarding diagnosis or treatment:
Patient continues to meet the diagnostic criteria for Schizoaffective Disorder. The treatment plan has been adjusted to include a trial of a new antipsychotic medication to address the persistent auditory hallucinations. The patient has been informed of the potential side effects and benefits of the new medication.
Professional supports in the community:
* Community Mental Health Team.
* GP, Dr. Anya Sharma.
* Local support group for individuals with mental health conditions.
Weekend plan / overnight leave:
* Patient will be spending the weekend at home with her mother.
Mental state:
Patient presented with good rapport and cooperation. Speech was coherent, though at times circumstantial. Mood was stable, affect was congruent. Thought content revealed some paranoid ideation, but no active delusions. No current hallucinations were reported. No suicidal or homicidal ideation was expressed. Cognition was intact. Insight and judgement were fair.
Current risk:
Patient is currently at low risk of harm to self or others. Suicidal ideation is present but without intent or plan. The patient has a strong support system and is actively engaged in therapy.
Treatment plan:
* Continue current medication regimen, with a trial of a new antipsychotic.
* Continue individual therapy sessions twice a week.
* Continue group therapy sessions weekly.
* Schedule follow-up appointment in two weeks.
Any other concerns:
* Patient expressed concern about the stigma associated with her diagnosis. "I worry what people will think," she stated.
Clinical Review APARC [Date of review] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single line.)
Attended by:
[Names and roles of clinical team members present] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single line.)
This week working on:
[Current therapy focus, strategies, themes or verbatim quotes] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Improvements noted:
[Observed improvements in mental state, behaviour or functioning; include relevant verbatim quotes] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Ongoing challenges:
[Persisting psychological or functional difficulties] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Main personal supports in the community:
[People supporting the patient (e.g. family, relatives, friends)] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a list.)
Transition meeting:
[Status of transition meeting planning (e.g. planned / not decided / not needed)] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single line.)
Any concerns related to medications:
[Concerns regarding adequacy, effectiveness, adherence, side effects] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Further information regarding diagnosis or treatment:
[New or updated information regarding diagnosis, clarification, or treatment changes] (Only include if explicitly mentioned in transcript, context or clinical note. Write in paragraphs.)
Professional supports in the community:
[Support agencies or professionals involved (e.g. community mental health team, GP, NDIS, Mentis Assist)] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Weekend plan / overnight leave:
[Details including destination, dates, time, and leave purpose] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Mental state:
[Observations on rapport, cooperation, speech, mood, affect, thought content/themes, delusions, hallucinations, suicidal or homicidal thoughts, cognition, insight, and judgement] (Only include if explicitly mentioned in transcript, context or clinical note. Write in paragraph format.)
Current risk:
[Assessment of risk to self or others, including suicide, self-harm, self-neglect, aggression] (Only include if explicitly mentioned in transcript, context or clinical note. Write in paragraph format.)
Treatment plan:
[Updates to medication, allied health involvement, referrals, discharge planning, or follow-up appointments] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Any other concerns:
[Additional concerns or issues raised; include relevant verbatim quotes] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or support needs – 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 the information has not been explicitly mentioned in your output. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)