Mental Health Care Plan

This is a Mental Health Care Plan [creation/review]. 1. Consent [consent] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Document the patient's consent to the mental health care plan.) 2. Relevant History (Repeat the following format for each principal problem or diagnosis. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate diagnoses that were not discussed. Do not include non-mental health-related conditions in this section.) - Principal Problem/Diagnosis: [diagnosis] (Identify the mental health diagnosis or problem discussed or in context.) - Mental Health History/Treatment: [mental health history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Summarise the patient's past mental health episodes, diagnoses, previous treatments, e.g. therapy, medications, hospitalisations, and their perceived effectiveness, as discussed in the consult or found in context.) - Language spoken at home: [language] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. State the primary language spoken at the patient's home.) - How well does the person speak English: [English proficiency] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the patient's proficiency in English, e.g. fluent, good, limited, interpreter required.) - Family History: [family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe relevant family history of mental illness, e.g. depression, anxiety, psychosis, addiction.) - Social History: [social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the patient's current social circumstances, including relationship status, significant relationships, work, study, social support network and living situation.) - Does the person live alone: [lives alone] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. State yes or no and provide details if discussed.) - Highest education level completed: [education level] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.) - Alcohol: [alcohol use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Quantify alcohol use, e.g. frequency and number of standard drinks per session/week, and any concerns or attempts to reduce.) - Smoking: [smoking status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. State smoking status: current smoker with amount if stated, ex-smoker with quit date if stated, or never smoked.) - Quitting Stage: [quitting stage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. If a smoker, identify their stage of change, e.g. pre-contemplation, contemplation, preparation, action, maintenance.) - Allergies: [allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List all known patient allergies, including drug, food, and environmental, and reported reactions.) - Personal History/Lifestyle Issues: [personal history and lifestyle] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe other relevant personal history or lifestyle factors impacting mental health, e.g. significant life events, trauma, financial stress, sleep hygiene, diet, exercise habits.) 3. Presenting Complaint [presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate symptoms or diagnoses that were not discussed. Provide a detailed summary of the patient's current mental health issues and symptoms and why they are accessing psychological supports, including where discussed: mood and ability to experience joy; physical symptoms such as weight changes, sleep disturbances, fatigue; cognitive symptoms such as thoughts of self-worth, guilt, concentration difficulties; safety concerns including thoughts of self-harm and suicide, domestic violence, bullying; anxiety symptoms such as panic attacks, generalised worry, social anxiety, phobias; manic symptoms if applicable such as inflated self-esteem, reduced need for sleep, racing thoughts, risky activities or overspending; OCD symptoms if applicable such as recurrent intrusive thoughts, urges, images causing distress, repetitive behaviours or compulsions.) 4. Mental State Examination (MSE) Findings [MSE overview] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate MSE findings that were not discussed or clearly implied. For findings within normal limits and not specifically discussed as abnormal, use: NAD for no abnormalities detected, euthymic for mood, congruent for affect, and no formal thought disorder for thought form.) - Appearance and General Behaviour: [appearance and behaviour] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe findings, e.g. well-groomed, dishevelled, agitated, restless, withdrawn, cooperative, eye contact. If not specifically remarked upon or within normal limits, state NAD.) - Speech: [speech] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe characteristics, e.g. volume, rate, rhythm, coherence, content. If not specifically remarked upon or within normal limits, state NAD.) - Mood: [mood] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Document the patient's subjective emotional state as reported. If explicitly described as balanced and content, state euthymic.) - Affect: [affect] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the observed emotional expression, e.g. congruent or incongruent with mood, range, lability, intensity. If observed as appropriate and consistent with mood, state congruent.) - Thought Form: [thought form] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the organisation and flow of thoughts, e.g. logical and coherent, flight of ideas, circumstantial, tangential, thought blocking, looseness of associations. If observed as clear and organised, state no formal thought disorder.) - Thought Content: [thought content] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate thought content that was not discussed. Document preoccupations, themes, or specific unusual thoughts, e.g. suicidal ideation, self-harm, homicidal ideation, delusions, obsessions, compulsions, phobias, persecutory thoughts. Clearly note if no such thoughts are elicited or present.) - Perception: [perception] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate perceptual findings that were not discussed. Document any presence of hallucinations, illusions, or dissociative experiences. Clearly note if no such experiences are elicited or present.) - Cognition: [cognition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Briefly describe general cognitive function as observed, e.g. alert, oriented, concentration, memory. If not specifically remarked upon or within normal limits, state NAD.) - Insight: [insight] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the patient's understanding of their mental health condition, its impact, and the need for treatment, e.g. good, partial, limited, poor, absent. Relate to the patient's own words if possible.) - Judgement: [judgement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe the patient's ability to make rational decisions and understand consequences, e.g. good, impaired. Provide examples if discussed.) - Orientation: [orientation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Document if the patient is oriented to time, place, and person. If within normal limits, state NAD.) (Only include the following if specifically discussed or assessed as a focus of the consult; otherwise omit entirely.) - Sleep Patterns: [sleep patterns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Detail sleep disturbances, e.g. initial insomnia, middle insomnia, early morning wakening, hypersomnia, or state NAD.) - Appetite/Eating Patterns: [appetite and eating] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe any changes in appetite or disturbed eating patterns, or state NAD.) - Attention/Concentration: [attention and concentration] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe any difficulties with attention or concentration, or state NAD.) - Motivation/Energy: [motivation and energy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe observed or reported levels of motivation and energy, e.g. anergia, increased energy, psychomotor retardation or agitation, or state NAD.) - Memory: [memory] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe any observed or reported impairments in short-term or long-term memory, or state NAD.) 5. Risk of Self-Harm or Suicide - Suicidal Ideation, Intent, Current Plan, Risk to Others: [risk assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate risk information that was not discussed. Provide a detailed summary of any discussion regarding suicidal ideation including presence, frequency, and intensity; intent; any current plan including means and access; and any expressed risk to others. Document protective factors discussed.) 6. K10/DASS21 Scores [K10 or DASS21 scores] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Include K10 or DASS21 scores from the pre-consult context if present, or as discussed in the consult.) 7. Goals of Treatment (Repeat the following format for each principal problem or diagnosis identified in section 2. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate goals or actions that were not discussed. Do not include non-mental health-related conditions in this section.) Principal Problem/Diagnosis: [diagnosis] - Goals: [goals] (List specific, measurable, achievable, relevant, time-bound goals for this problem, developed collaboratively with the patient.) - Actions/Tasks: [actions and tasks] (List the specific actions the patient will undertake, and any treatments, e.g. medication changes, therapy continuation, lifestyle adjustments, or services, e.g. psychologist sessions, psychiatrist review, required to achieve these goals.) 8. Next of Kin/Support Person [next of kin] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. State the name and relationship of the patient's next of kin or support person, if discussed and appropriate to document.) 9. Follow-up Plan [follow-up plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Do not generate follow-up plans that were not discussed. Document the agreed-upon follow-up plan, including date for next review, and any safety netting advice provided.) (Prioritise detailed extraction for mental health discussions. Use Australian English spelling throughout.)