NF Psychiatriac assessment note

Telehealth Appointment **Time:** [Insert time of appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Date:** [Insert date of appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Present:** [e.g., Patient alone / Patient with parent / Partner present] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Referral Details** - [Mention who referred the patient and the reason for referral. List any assessments or investigations completed prior to the appointment.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Briefly summarise collateral history from other clinicians (e.g., psychologist), including outcomes of assessments relevant to this interview.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Demographics** - [Paragraph outlining patient name, gender, age, social situation, occupation, hobbies, and living situation.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Presenting Issues** - [Describe presenting complaints in the patient’s own words, including symptoms, intensity, duration, and associated factors.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [List DSM-5 ADHD hyperactivity/impulsivity symptoms present. Include duration, severity, and impact on life/work/relationships.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [List DSM-5 ADHD inattentive symptoms present. Include duration, severity, and impact on life/work/relationships.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Include any symptoms relevant to diagnostic criteria for major depressive disorder or anxiety disorders.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Include discussion about suicidal ideation or self-harm.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Summarise patient’s sleep, diet, appetite, and exercise patterns.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Summarise patient’s screen and social media use.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **ADHD Symptoms** - [List DSM-5 inattentive symptoms present.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [List DSM-5 hyperactivity and impulsivity symptoms present.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Features of Autism Spectrum Disorder** - [List difficulties in verbal and non-verbal communication and associated impacts.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [List any restricted, repetitive behaviours, interests, or activities.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Describe sensory sensitivities, such as sensitivity to sounds or smells.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Outline DSM-5 criteria met for autism spectrum disorder.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Mental Health History** - [List previous psychiatric diagnoses, therapies, self-harm behaviours, hospitalisations, and treating clinicians.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Medical History** - [List of past and current medical conditions.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Objective** - [Vital signs] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Physical or mental state examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Completed investigations and their results] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **ADHD-Related Cardiac History** - [Mention any relevant cardiac problems, family history of sudden cardiac death, or hypertension.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Medication History** - [List current and past psychiatric and non-psychiatric medications.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Allergies** - [List allergies or write "Nil reported"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Drug and Alcohol History** - [Mention current and past use, frequency, impact on functioning or relationships.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Forensic History** - [Summarise any forensic or legal history] (If not mentioned, write "Nil reported.") **Family History** - [Mention family history of mental illness, ADHD, autism, or suicide.] (If not mentioned, write "There was no reported family history of mental health conditions or suicide.") **Developmental History** - [Details about patient’s birth, parents, complications, illnesses.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Comment on developmental milestones, and any delays or treatments.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Describe early attachments and childhood temperament.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Mention any early trauma or significant events.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Describe school experience.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Include history of behavioural difficulties at home or school.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Include ADHD symptoms noted in childhood.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Functioning** - [Summarise current school, work, or social functioning, with detail about the severity of impairment.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Mental State Examination** [Detailed prose-style psychiatric mental state exam, including engagement, appearance, speech, thought process, mood and affect, insight, judgement, cognition, and relevant negatives.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) **Impression** [Detailed biopsychosocial formulation referencing symptoms, diagnosis, social/environmental factors.] [Include all relevant DSM-V diagnoses and criteria met.] [Document relevant symptoms absent.] [Identify differential diagnoses.] [Describe impacts on functioning and relationships.] [Comment on whether ADHD symptoms are secondary to another disorder or substance use.] (If not mentioned, write "Based on the available information the ADHD symptoms are not secondary to a separate medical or psychiatric illness or substance use.") [Include whether ADHD symptoms were present in early childhood or not confirmed.] [Comment on prognosis, protective factors, and patient strengths.] [Comment on risk to self or others. If not mentioned, write "There were no immediate risks identified."] **Today we discussed:** - [Treatment planning point 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - [Treatment planning point 2] - [Treatment planning point 3] (Continue as needed.) **Recommendations for GP** [If mentioned, list relevant GP recommendations in cordial language.] (If not mentioned, write "Nil.") **Recommendations for Patient** 1. [Please do (e.g., begin medication, attend follow-up, begin CBT)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 2. [Please attend neuropsychological assessment, if recommended.] 3. [Please consider engaging with allied health or other services.] (Continue as needed.) Please contact [clinic contact email address] if you require any clarification or assistance. (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (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 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 – just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)