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Psychiatrist Template

New patient OneNote records

A professional Psychiatrist template for healthcare professionals.
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About this template

Need a clear and comprehensive record of your patient's mental health? This 'New Patient OneNote Records' template is designed for psychiatrists and mental health professionals. It helps you document everything from presenting issues and mood to past psychiatric history and treatment plans. This template is perfect for creating detailed and organised clinical notes, ensuring all crucial information is captured. With Heidi, this template can be easily populated from your patient's visit transcript, saving you time and improving the accuracy of your documentation.

Preview template

{ "example_output": "Appointment: 01/11/2024\n\nDEMOGRAPHICS:\nDate of Birth: 12/03/1988\nAge: 36, Gender: Male, Single, Living alone, Employed as a software engineer, No pension information available.\n\nPRESENTATION:\nPatient presents today for an initial psychiatric evaluation. He reports experiencing symptoms of low mood, anxiety, and difficulty concentrating for the past six months. He reports that these symptoms have been impacting his work and social life.\n\nMOOD:\n* Patient reports pervasively low mood, stating, \"I just don't enjoy things anymore.\"\n* Reports feeling sad and hopeless.\n* Reports anhedonia.\n* Reports problems with sleep, appetite, and concentration.\n\nPSYCHOSIS:\nNil\n\nANXIETY DISORDERS:\n* Reports symptoms of generalised anxiety disorder, including generalised apprehension, restlessness, and difficulty concentrating.\n* Patient reports, \"I worry constantly about everything.\"\n\nEATING DISORDERS:\nNil\n\nADHD:\nNil\n\nASD:\nNil\n\nPAST PSYCHIATRIC HISTORY:\n* Patient reports a previous diagnosis of major depressive disorder, diagnosed 3 years ago. He was treated with sertraline and psychotherapy.\n* Patient was previously seen by Dr. Emily Carter.\n\nFAMILY PSYCHIATRIC HISTORY:\n* Patient reports a family history of depression in his mother.\n\nDRUG AND ALCOHOL HISTORY:\n* Patient reports occasional alcohol use, typically one or two drinks on weekends. He denies any history of illicit drug use.\n\nGAMBLING DISORDER:\nNil\n\nPAST MEDICAL HISTORY:\n* Patient reports a history of seasonal allergies.\n\nMedication contraindication screen:\n* Patient reports no known medication contraindications.\n\nFORENSIC HISTORY:\nNil\n\nALLERGIES:\n* Seasonal allergies\n\nMEDICATION:\n* Sertraline 50mg daily\n\nPERSONAL HISTORY:\n\t• FAMILY:\n\tPatient is estranged from his father, but has a close relationship with his mother and sister.\n\t• CHILDHOOD:\n\tPatient reports a relatively stable childhood.\n\t• SCHOOLING:\n\tPatient completed a Bachelor's degree in computer science.\n\t• WORK:\n\tPatient is employed as a software engineer.\n\t• RELATIONSHIPS:\n\tPatient is single and has not been in a long-term relationship.\n\t• PREMORBID PERSONALITY:\n\tPatient was previously described as a quiet and introverted individual.\n\nMENTAL STATE EXAMINATION:\n\t• Appearance:\n\tPatient appears his stated age, well-groomed, and appropriately dressed.\n\t• Behaviour:\n\tPatient is cooperative and displays normal psychomotor activity.\n\t• Speech/Language:\n\tSpeech is normal in rate, rhythm, and content.\n\t• Mood:\n\tPatient reports low mood.\n\t• Affect:\n\tAffect is constricted.\n\t• Thought form:\n\tThought form is linear and goal-directed.\n\t• Thought tempo:\n\tThought tempo is normal.\n\t• Thought content:\n\tPatient reports negative thoughts about himself and the future.\n\t• Perception:\n\tNo perceptual disturbances noted.\n\t• Insight:\n\tPatient demonstrates good insight into his condition.\n\t• Judgement:\n\tPatient demonstrates good judgement.\n\t• Cognition:\n\tCognition is intact.\n\n**DIAGNOSIS:**\nMajor Depressive Disorder, Recurrent.\n\n**TREATMENT:**\n* Continue Sertraline 50mg daily.\n* Recommend Cognitive Behavioral Therapy (CBT).\n* Schedule a follow-up appointment in four weeks to assess response to treatment.\n}
Appointment: [document today’s date] (DD/MM/YYYY) DEMOGRAPHICS: [document patient’s date of birth in] (DD/MM/YYYY) [document patient demographics including age, gender, relationship status, living arrangements, employment details, pension information, and other relevant details] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in bullet point sentences or words.) PRESENTATION: [describe the patient's presenting issues, reasons for visit, and any relevant context] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in sentences or dot points.) MOOD: [describe the patient's mood, including any relevant observations or patient-reported information] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points with words, phrases, or sentences. Include patient’s quotes.) [describe any symptoms of hypomania, mania, or bipolar depression] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) PSYCHOSIS: [document any symptoms or history of psychosis] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) ANXIETY DISORDERS: [describe any symptoms of generalised anxiety disorder] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) [describe symptoms of social anxiety] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) [describe symptoms of panic attacks and agoraphobia] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) [describe symptoms of obsessive compulsive disorder] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) [describe symptoms of PTSD] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) EATING DISORDERS: [document any symptoms or history of eating disorders] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) ADHD: [describe any symptoms or history of ADHD] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points. Include patient’s quotes.) ASD: [document any symptoms or history of Autism Spectrum Disorder (ASD)] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) PAST PSYCHIATRIC HISTORY: [document the patient's past psychiatric history including previous diagnoses, treatments, hospital admissions, previous psychologists or psychiatrists] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) FAMILY PSYCHIATRIC HISTORY: [describe any family history of psychiatric conditions] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) DRUG AND ALCOHOL HISTORY: [provide detailed description of the patient's history of drug and alcohol use] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) GAMBLING DISORDER: Lie: [document any instances of lying related to gambling] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) Chase losses: [document any instances of chasing losses related to gambling] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) PAST MEDICAL HISTORY: [document the patient's past medical history including relevant conditions or surgeries] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) Medication contraindication screen: [document any contraindications for medications including family history of specific conditions] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) FORENSIC HISTORY: [document any relevant forensic history] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) ALLERGIES: [document any known allergies] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) MEDICATION: [document current medications including dosages and any over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot points.) PERSONAL HISTORY: - FAMILY: [document family history and dynamics] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) - CHILDHOOD: [document relevant details about the patient's childhood] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) - SCHOOLING: [document the patient's educational history] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) - WORK: [document the patient's employment history] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) - RELATIONSHIPS: [document the patient's relationship history] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) - PREMORBID PERSONALITY: [document the patient's personality before the onset of any psychiatric conditions] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in brief bullet points.) MENTAL STATE EXAMINATION: - Appearance: [document the patient's appearance] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Behaviour: [document the patient's behaviour] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Speech/Language: [document the patient's speech and language] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Mood: [document the patient's mood] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Affect: [document the patient's affect] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Thought form: [document the patient's thought form] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Thought tempo: [document the patient's thought tempo] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Thought content: [document the patient's thought content] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Perception: [document the patient's perception] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Insight: [document the patient's insight] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Judgement: [document the patient's judgement] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) - Cognition: [document the patient's cognition] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely.) DIAGNOSIS: [document the patient's diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in full sentences.) TREATMENT: [document the patient's treatment plan] (Only include if explicitly mentioned in transcript, context or clinical note; otherwise omit completely. Write in dot point sentences or statements.) (For each section, only include if explicitly mentioned in transcript, context or clinical note, 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. If any information related to a placeholder has not been explicitly mentioned, 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.)
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Specialty

Psychiatrist

Used

6 times

Type

Note

Last edited

9/9/2025

Created by

Matthew Hocking

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