YASU Review Note

**Young Adult Support Unit – Review Appointment** **<u>Situation</u>** **Date:** [date of appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in format DD/MM/YYYY.) **Time:** [time of appointment](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Attendees:** [list of attendees including patient and other family members] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Clinician:** [clinician name and role](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Appointment type:** [document type of appointment such as mode, setting and location](Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **[document that patient has arrived for appointment and provided consent]**(Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) **Background:** [document patient's name, pronouns, age, medical condition and presenting problem] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in paragraphs of full sentences.) **<u>Presentation:</u>** [document mental state and presentation observations such as dressing, appearance, affect, speech, and thought content] (Only include observations explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each item on a new line.) (If the appointment was a phone or telehealth session, write the following. Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit entirely.) "- Pt's appearance was unable to be assessed due to phone appt" **Current Risks Identified:** [document risks identified in session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If no risks were identified, print "No risks identified in session.") **Patient reports/updates** [document patient-reported information and updates since last appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) **Therapy goals/session focus:** [document therapy goals and session focus] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write in full sentences.) **Intervention:** [document interventions used in session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each new intervention item on a new line.) **Plans:** [document plan including next appointment date, follow-ups and referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely. Write as a bullet point list, with each item on a new line.)