FULL PSYCHIATRIC ASSESSMENT

(You must only include information if it is explicitly mentioned in the transcript, contextual notes or clinical note. If information is missing from the transcript, then leave blank.) (Refer to the patient by their first name.) (You must use "woman" or "man" instead of "female" or "male" when referring to the patient's gender.) (When you are using direct quotes, you must only write short quotes and only use them occasionally.) (Make all headings formatted in bold.) **[PATIENT'S FULL NAME], DOB [PATIENT'S BIRTHDAY], [PATIENT'S MEDICAL RECORD NUMBER], [PATIENT'S ADDRESS], [PATIENT'S EMAIL ADDRESS], [PATIENT'S TELEPHONE NUMBER]** (You must write this all in one line with no line breaks. You must write this formatted in bold and in all caps.) **CIRCUMSTANCES OF REFERRAL** [Patient's name, age, gender, and previous psychiatric diagnoses] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) [Reason for referral] (This should be one sentence only; include only if explicitly mentioned in the transcript; otherwise omit completely.) **CANCER HISTORY** (Only include this section if cancer is mentioned in the transcript; otherwise omit entirely.) [Patient's cancer diagnosis and history of cancer symptoms, cancer diagnosis and treatment] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in full sentences, chronological order, and include a timeline where dates are provided.) **HISTORY OF PRESENTING SYMPTOMS** [Patient's main psychiatric symptoms and concerns] [Timeline of main psychiatric symptoms and concerns] [Relationship between cancer and psychiatric symptoms] [Patient's description of mental health impact] [Patient's description of cancer impact] [Patient's emotional responses to current situation] [Patient's report of specific symptoms] [Patient's reflection on past experiences] [Patient's future outlook] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write using full sentences and paragraph format. Include events in chronological order with dates if provided.) **PSYCHIATRIC HISTORY** [Patient's previous mental health history] [Previous mental health assessments] [Relevant information from patient's witness statement] [History of suicidality and suicide attempts] [History of deliberate self-harm] [Other history of deliberate or accidental harm] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in detailed full sentences without quotes.) **MEDICAL HISTORY** [Patient's current physical health concerns] [Patient's past physical health issues] (You must not include family history. Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in detailed full sentences without quotes.) **MEDICATIONS** - [Patient's current medications, including doses and frequency] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) **PERSONAL HISTORY AND DEVELOPMENTAL HISTORY** [Patient's family background] [Patient's childhood experiences] [Childhood illnesses and early developmental milestones] [Patient's developmental and educational history] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write using full sentences and paragraph format in chronological order with dates if provided.) **SOCIAL CIRCUMSTANCES** [Patient's current social circumstances] [Patient's daily activities and limitations] [Patient's current functioning] [Patient's current housing and employment] [Patient's current relationships and support] [Patient's financial circumstances] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in full sentences and paragraph format, chronological order if dates provided.) **SUBSTANCE USE** [Patient's substance use history] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in full sentences without quotes.) **FAMILY HISTORY** [Family's mental health and medical history] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write in full sentences without quotes.) **MENTAL STATE EXAMINATION** "Appearance and behaviour:" [Appearance and behaviour] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) "Speech and motor:" [Speech and motor function] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) "Mood and affect:" [Mood and affect] (Include short quotes where applicable; only include if explicitly mentioned in the transcript; otherwise omit completely.) "Thought process and content:" [Thought process and content] (Include short quotes where applicable; only include if explicitly mentioned in the transcript; otherwise omit completely.) "Perceptions:" [Hallucinations] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) **STANDARDISED TOOLS** (Write all results of standardised tools or questionnaires mentioned in the transcript. If none are mentioned, omit this section.) **IMPRESSION AND OPINIONS** [Patient name and age] [Summary of reported issues] [Diagnostic impression] [Rationale for diagnosis] [Differential diagnoses considered] [Opinion on cause of current symptoms] [Corroboration of patient's reports] [Discussion about treatment options, including all treatment options discussed with the patient, the patient's views on treatment options, and information about risks and benefits of different treatments.] (Only include if explicitly mentioned in the transcript; otherwise omit completely. Write using full sentences and paragraph format.) **RISK TO SELF** [History of self-harm, suicidal thoughts, or suicide attempts] [Assessment of injury severity] [Assessment of current suicide risk] [Future mental health risks] (If the patient has no history of suicidality or self-harm in the transcript AND has no current suicidal thoughts in the transcript, then write “No risk of harm to self identified.”) **RISK TO OTHERS** [History of harming others] [History of violence] [History of aggression] [Thoughts of harming other people] [Current thoughts of harming other people] [Forensic history or contact with police] (If the patient has no history of violence AND has no thoughts of violence AND has no forensic history OR there is no information in the transcript about violence or harm to others, then write “No risk of harm to others evident.”) **RECOMMENDATIONS** [Plan for medications] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) [Plan for psychological therapy] (Only include if explicitly mentioned in the transcript; otherwise omit completely.) [Follow up appointment date, time and place] (If the patient is not going to receive follow-up, then write “Discharged from this clinic.”) (Only include if explicitly mentioned in the transcript; otherwise omit completely.) Always include as the last recommendation: If you are feeling overwhelmed or suicidal, 24h crisis counselling is available from the Samaritans on 116 123 or advice from NHS 111 (option 2). If you are feeling unsafe, mental health support is available in every UK emergency department or via ambulance (999). **COPY TO:** [Patient's GP name and address] (If the GP address is the same as the patient's address, then you must put “GP - UNKNOWN” in this section.) [Other CCs] (Include the referrer if known and any other CCs mentioned during the session.) (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 it was not mentioned — simply leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)