**JANE DOE, DOB 01/01/1990, 1234567, 10 DOWNING STREET, LONDON, SW1A 2AA, jane.doe@email.com, 07700 900000**
**Diagnosis:**
- Major Depressive Disorder, Recurrent, Severe
- Generalised Anxiety Disorder
**Current medications:**
- Sertraline 100mg daily
- Pregabalin 75mg twice daily
[Update on psychiatric issues] Jane reports feeling increasingly overwhelmed by her symptoms of low mood and anxiety. She describes feeling hopeless about the future and has been experiencing significant anhedonia. She reports difficulty sleeping and changes in appetite. She has been isolating herself from friends and family.
[Update on medical issues] Jane reports no new medical issues.
[Update on medications] Jane reports that the sertraline is helping a little, but the anxiety is still very high. She is tolerating the pregabalin well.
**RISK**
Jane denies any current suicidal ideation or plans for self-harm. She denies any intent to harm others.
**RECOMMENDATIONS**
We discussed increasing the dose of sertraline to 150mg daily. I have provided a prescription for this.
We discussed the possibility of adding a course of Cognitive Behavioural Therapy (CBT) to help manage her anxiety. I have provided a referral to the local IAPT service.
Follow up appointment date, time and place: 15 November 2024, 10:00 AM, at the clinic.
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:**
Dr. John Smith
123 High Street
London, SW1A 1AA
(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.)
(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. You must write this in all caps. Copy this information from previous linked sessions or documents in context.)
**Diagnosis:** (You must write in a Goldilocks voice using bulleted list. Take the diagnoses from previous letters unless changes to the diagnoses are discussed during the session.)
- [Psychiatric diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current medical diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Current medications:** (You must write medication names and doses using a bulleted list. Take the medications from previous letters unless changes to the medications are discussed during the session.)
- [Current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(You must write using a super detailed voice. You must use full sentences and paragraph format when writing. You must only use information from the transcript. You must not use information from the contextual notes.)
[Update on psychiatric issues] (Only include if explicitly mentioned in the transcript; otherwise omit completely.)
[Update on medical issues] (Only include if explicitly mentioned in the transcript; otherwise omit completely.)
[Update on medications] (Only include if explicitly mentioned in the transcript; otherwise omit completely.)
**RISK** (You must write using a detailed voice. You must use full sentences when writing.)
[Harm to self] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Harm to others] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**RECOMMENDATIONS** (You must write in a detailed voice. Do not number points. Do not use quotes. Do not include information that is not in the transcript. Each line must start with a new paragraph break. If there are requests for someone else, e.g. the GP, you must phrase this as a polite question.)
[Plan for medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Plan for psychological therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; 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, contextual notes or clinical note; 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:** (Obtain information from previous correspondence or context.)
[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] (You must 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.)
