Nicola Lodge phone followup

"The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks." Psychiatry Progress Note: Date of Review: [date of psychiatric review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Time of Review: [time of psychiatric review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Patient Name: [patient's full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Date of Birth: [patient's date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medical Record Number: [patient's medical record number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Location: [name and type of long-term care facility] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Reviewed with: [names and titles of staff members from the long-term care facility involved in the review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Reason for Review: [describe the specific purpose of this psychiatric review, such as follow-up on a previous recommendation, monitoring of symptoms, medication review, or response to a new event] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Review of Pertinent Clinical Information (from nursing/care providers): - Behavioral Observations: [summarize current behavioral issues, changes in behavior, frequency, intensity, and triggers, including any agitation, aggression, withdrawal, or repetitive behaviors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Mood and Affect: [document observations regarding the patient's mood (e.g., sad, anxious, irritable, flat) and affect (e.g., congruent, restricted, labile)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Cognition: [report on cognitive status as observed by staff, including changes in memory, orientation, attention, or decision-making abilities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Sleep Patterns: [describe recent sleep patterns, including onset, maintenance, duration, and any disturbances like insomnia, hypersomnia, or nightmares] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Appetite and Nutritional Intake: [detail observations related to appetite, food refusal, changes in weight, or specific dietary concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Activities of Daily Living (ADLs) and Functional Status: [report on the patient's ability to perform ADLs, changes in functional independence, and need for assistance with tasks such as hygiene, dressing, or mobility] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Social Interaction: [describe the patient's engagement in social activities, interactions with peers and staff, and any signs of social isolation or withdrawal] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Physical Health Concerns: [document any new or ongoing physical health issues reported by staff, including pain, infections, or other medical symptoms that may impact psychiatric status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Medication Adherence and Side Effects: [report on the patient's adherence to prescribed medications and any observed or reported side effects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Staff Concerns/Questions: [list any specific concerns, questions, or observations raised by the long-term care facility staff during the review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Chart Review: - Current Medications: [list all current psychiatric and non-psychiatric medications, including dosages, routes, and frequencies, with any recent changes noted] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Past Psychiatric History: [summarize relevant past psychiatric diagnoses, treatments, hospitalizations, and responses to previous interventions as documented in the chart] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Relevant Medical History: [document any pertinent medical conditions, allergies, and significant medical events from the chart that may influence psychiatric care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Recent Lab Results/Diagnostics: [mention any recent relevant laboratory results, imaging, or diagnostic studies reviewed that are pertinent to the patient's psychiatric or overall health status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Previous Psychiatric Recommendations: [summarize previous psychiatric recommendations from prior notes and the patient's response or adherence to them] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Recommendations: - Medication Adjustments: [provide specific recommendations for changes to psychiatric medications, including dosage adjustments, new medications, discontinuation of current medications, or changes in administration schedule, along with the rationale] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Behavioral Interventions: [suggest non-pharmacological interventions or strategies for managing challenging behaviors, improving mood, or enhancing cognitive function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Follow-up Plan: [outline the plan for future psychiatric follow-up, including the proposed interval for the next review and any specific instructions for monitoring] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Staff Education/Guidance: [provide specific guidance or education points for the long-term care facility staff regarding patient care, symptom monitoring, or intervention implementation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Further Investigations: [recommend any additional lab tests, diagnostic studies, or referrals to other specialists as deemed necessary] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - Communication with Family/Guardians: [suggest if and how to communicate updates or recommendations to the patient's family or legal guardian] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. " Dr. [Psychiatrist's Name](Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Geriatric Psychiatrist " (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. Ensure the note is detailed and comprehensive)