Progress Note for Inpatients

Background: - [duration of admission thus far] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [legal status of the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Demographics: describe basic demographic details of the patient including age, marital status, employment, source of income, who they live with, any supports and services engaged to] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Diagnosis: list the diagnoses of the patient starting with most important and ending with past diagnoses and then suspected diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Treatment: list the current medications and doses the patient is taking] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Progress: - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [describe recent neurovegetative symptoms including sleep, appetite, energy and overall function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [describe recent mood symptoms, anxiety symptoms, psychotic symptoms and other symptoms related to their diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [describe response to treatments and side-effects from treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of EMR: - [describe findings from nursing notes, legal documents and other entries from within the medical record discussed during the review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mental State Examination: - [appearance, behaviour, cooperation, mood, affect, speech, thought form, thought content such as delusions, overvalued ideas, obsessions and themes, cognition, insight, judgement and risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Findings: - [vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [laboratory and diagnostic test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Risk: - [describe risk towards self and others - current levels and background levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Impression: - [progress since the last review - whether improving, stable or worsening] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [clinical impressions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [main issues identified during this review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - [nursing observations required] (1 is constant, 2 is every 15 minutes, 3 is every 30mins and 4 is every hour) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [describe leave available to the patient] (escorted or unescorted and for how long) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [treatment plan, including medications, therapies, and interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [follow-up plans and appointments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [patient education and counseling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, 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, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)