Follow Up Note

**Identifying Information** [Identifying Information] (Only include [Identifying Information] from contextual notes, otherwise leave blank) **ASSESSMENT** **General Assessment** [draft an assessment by describing diagnosis or differential diagnosis, key features supporting diagnosis, biopsychosocial factors that contribute to vulnerabilities, stressors or events that impact current presentation, biopsychosocial factors that are protective, potential obstacles or barriers that could impact treatment or recovery, priority areas for treatment] (Only include details if explicitly discussed in the transcript. Use complete sentences, formal structure, moderate details) **Nicotine Assessment** [Insert details about nicotine use and plans for nicotine use] (Include details if explicitly discussed, otherwise use data from contextual notes and indicate details are from prior encounter) **Risk Assessment** Pt is at chronically elevated risk of harm to self or others based on: [insert risks for harm to self or others, including but not limited to prior psychiatric hospitalizations, psychiatric diagnosis, history of suicide attempt, current suicidal thinking, history of violence, history of incarceration, history of substance use] (only include details discussed in transcript, otherwise leave blank). These risks are mitigated by: [insert protective factors, including but not limited to denial of suicidal/homicidal thoughts, plans or intent, willingness and motivation for treatment, future oriented thinking, sense of responsibility to family, stable housing, stable employment, family support, denies access to guns] (only include details discussed in transcript, otherwise leave blank) **Diagnoses** - [Insert the diagnosis, relevant DSM-5 criteria, psychological scales/questionnaires.] (Only include diagnosis details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **PLAN** - [Planned investigations.] (Only include [investigations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Medication plans] (Use list form, write in this format: CONTINUE, INCREASE, DECREASE or STOP, Medication name, dosage and frequency (start date, inc or dec date). Include medication plans explicitly stated in transcript, contextual notes, or clinical note, otherwise omit completely.) - [Psychotherapy plans and strategies.] (Only include psychotherapy plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Planned family meetings & collateral information, psychosocial interventions.] (Only include family meetings and psychosocial interventions if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Follow-up appointments and referrals.] (Only include follow-up plans and referrals if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **SUBJECTIVE** **HPI** [Describe current issues and reasons for visit.] (Use minimal detail, only include what was explicitly mentioned in the transcript, contextual notes, or clinical note) **Review of Systems** [describe review of systems] (only include what was explicitly mentioned in the transcript, contextual notes, or clinical note) **OBJECTIVE** **Physical Exam** General: NAD MSK: no abnormal movements, no tics/tremors Pulm: no increased work of breathing **Mental Status Examination: ** APPEARANCE: appropriately groomed, casually dressed, appears stated age BEHAVIOR: Appropriate eye contact, facial expressions and posture. No psychomotor activation or retardation COGNITION: alert, able to attend to conversation FUND OF KNOWLEDGE: average for age/education on gross exam, no formal testing done ATTITUDE: calm, cooperative, communicative SPEECH: normal rate, rhythm, volume LANGUAGE: fluent English with no gross signs of dysarthria MOOD: [mood] AFFECT: THOUGHT PROCESS: coherent, linear, goal oriented. No derailment, flight of ideas, perseverance THOUGHT CONTENT: no suicidal/homicidal thoughts, plans or intentions. No apparent delusions, ideas of reference, phobias, or preoccupations PERCEPTIONS: no overt hallucinations or illusions INSIGHT: intact JUDGEMENT: intact (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 the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit it completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)