(If previous session findings or any additional information is supplied in the context tab or discussed, draw comparisons and flag any significant differences in the patient’s presentation e.g. changes in key symptoms. Additionally, populate the first paragraph of the "Background and past contacts" section in this note using the information in the context tab.)
**Background and past contacts:**
[Describe past contacts including dates, types of appointments, key issues discussed, and any interventions or treatments provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Describe current and planned reasons for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Employment History**
[Describe any change in the patient's employment, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Social History**
[Describe any change in the patient's current social circumstances, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Relationship History**
[Describe any update in the patient's Relationship History, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Drug and Alcohol History**
[Describe any update in the patient's drug and alcohol use, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[If active and ongoing drug or alcohol use, briefly note it here, even if no update on this] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Past Medical History**
[Describe any change in the patient's medical history, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[If relevant past medical history is available in context notes or mentioned in the transcript, briefly note it here, even if no update on this] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any information available on allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Medication History**
[Mention current medications including dosages, frequency, and any changes since the last visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[If currently in the medication adjustment process, summarize any relevant medication history here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Past Psychiatric History**
[Summarize past psychiatric history briefly and describe any change in the patient's Past Psychiatric History, if clearly mentioned in the transcript or at odds with what is documented in the context tab] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Update on Forensic History**
[Describe any change in the forensic history, if clearly mentioned in the transcript or at odds with what is documented in the context tab; if no changes say "No update"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Summary of Review:**
[Describe in detail patient's progress regarding main symptoms, diagnosis and concerns. Include information about:
- how the symptoms have changed or evolved since the last clinical review
- any change or progress in the duration/timing/location/quality/severity/context on key symptoms
- any new reported factors that worsen or alleviate the symptoms, including self-treatment attempts and their effectiveness
- any current impact on daily activities and how this has changed since the last appointment
- any reported side effects from medication and negative responses to side effect questions
- patient's assessment of medication effectiveness and any changes or improvements noticed
- patient's expressed concerns or issues regarding medication regimen
- progress made on the previous treatment plan, including what went well or not
- any psychoeducation by the clinician and the patient's response
- any new symptoms or concerns raised
- any negative responses to clinical questions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Mental Status Examination:** (You must write using full sentences and paragraph format; never use bullet points)
[Describe mental state examination including:
- appearance, behaviour, eye contact and psychomotor activity, noting any or no changes from last appointment
- mood and affect, noting any or no changes from last appointment
- speech & thought, noting any or no changes from last appointment
- perception, noting any or no changes from last appointment
- insight, noting any or no changes from last appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Risk Assessment:** (You must write using full sentences and paragraph format; never use bullet points)
[Describe current risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any history of self-harm, suicidal ideation, or attempts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Describe any history of violence or aggression, including towards others or property] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any protective factors, such as coping skills, resilience, or support systems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any current risk factors for self-harm, suicide, or violence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Describe any safety plans or interventions currently in place] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Capacity to Consent to Care and Treatment**
[Describe assessment of capacity or presumed capacity features, as applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Impression:** (You must write using full sentences and paragraph format; never use bullet points)
[Provide a summary of the case, including biopsychosocial factors contributing to the patient's condition, and detail why the diagnosis is appropriate in light of this] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Provide a summary of the feedback given to the patient and the discussion about this; it should clearly document the doctor's and the patient's views on all that was discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Provide a summary of the recommendations considered, and the discussion had about these; it should clearly document the doctor's and the patient's views on all the options discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document discussion on medication with detail, including doctor's and patient's opinion on this; end with the option decided on] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document discussion on any recommendations for additional support (therapy, coaching, resources); end with the option decided on] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document all patient concerns/questions about ADHD management or treatment plan, and the doctor's response to these; end with the action steps agreed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Plan:** (Use list items to write the plan section below; use as many bullet points as needed to capture all suggestions and plans discussed during the appointment)
[Outline the treatment plan including any changes to medications, therapy recommendations, follow-up appointments, and any other interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Always refer to the patient by their name, if available; only refer to them as "the patient" if there is no information about the patient's name in the patient details.)
(Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, or safety netting advice. Use only the transcript, contextual notes or clinical note as a reference for all information included. If any information related to a placeholder has not been explicitly mentioned, do not state this; simply omit the relevant placeholder or section.)
(Use as many sentences as needed to capture all relevant information from the transcript and contextual notes.)
