Initial Assessment Template - v23.10.25

(Only summarise and reformat the information provided in the transcript, contextual notes or clinical notes. Do not add diagnoses, management plans, or clinical recommendations. Do not generate new clinical content.) **Referral and Identification** [Note where the patient was located during the appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Note if patient showed ID and what kind of ID presented.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Note patient **Consent to record via AI transcribing tools**] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Write down if the patient consents for information to be shared with their GP, if info not available do not mention it] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Family History** [Describe family history and relationships in detail. Include information on: - parents and siblings or other family members they grew up with, including their age, occupation/academic achievement, their past medical or psychiatric history, and a brief note on their relationship quality, with each other and with the patient - any other relevant information on family events/marks, if applicable - any details on relevant family history of any mental health problems. Include any negative responses. - any details on physical health conditions that run in the family, particularly regarding heart problems, or other if relevant. Include any negative responses.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Personal History** [Describe personal history in detail. Include information about: - pregnancy, including maternal smoking or drinking, childbirth, any postnatal/perinatal problems - include any negative responses - gross overview of developmental history - childhood experiences, including any traumatic experiences, difficult relationships with family, mistreatment or abuse - school experiences, including information about social functioning, whether any bullying, ability to focus and organise self at school, behaviour in the classroom and specifically any symptoms of ADHD - academic achievement, including exam grades, whether they completed A-levels and/or went to university - any other trauma history - include any negative responses pertaining sexual, physical, emotional abuse] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Employment History** [Summarize employment history. Include information on: - types of jobs held, and duration - any dismissals or impulsive quitting - any details on relationships with work colleagues - current employment and struggles associated - include any negative responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Social History** [Describe social history including information about: - hobbies - any other relevant information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Relationships and Children History** [Describe the patient's relationship history in detail. Include information about: - current relationship status, including marital status, significant others, and duration of relationships - any significant past relationships, including quality and reasons for termination - any history of domestic violence or abuse if applicable - include any negative responses - details on children, i.e age, current occupation, any salient medical or psychiatric history, quality of the relationship with patient - include any negative responses - any other relevant details, including any negative responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Substance Use History** [Current or past recreational drug or alcohol use or dependence, and smoking. Specify the type of drug and quantities used. Specify if any help used in the past to manage substance use/alcohol or smoking] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Past Medical History** [Summarize past medical history. Include information about: - current physical health problems and diagnosis - past relevant physical health problems, including admissions, surgeries, and physical health diagnosis - Include any negative responses. - deny any history of cardiovascular disease or symptoms, glaucoma, epilepsy if applicable and mentioned in the transcript] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Medication** [Mention current medications, dosages, and any herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Allergies** [Include: - any history of allergies to medication - include any negative responses - any other allergies - include negative responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Forensic History** [Summarize patient's forensic history, if applicable. Include information about: - any history of legal issues, including arrests, charges, and convictions - any history of incarceration or probation - mention any history of violent behavior or aggression - describe any history of involvement with child protective services or other social services If all the above is denied, write "Denied any forensic history"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Past Psychiatric History** [Provide a detailed timeline of the patient's past psychiatric history. Include information about: - past psychiatric diagnosis established, including details on who made the diagnosis - any past period of self-reported mental health symptoms, even if not diagnosed. Describe symptoms presented, triggering and relieving factors, support sought, self-medicating behaviours and/or coping mechanisms, duration, temporal progression and how they resolved, if applicable - history of admissions due to psychiatric illness. Include any negative responses - history of past psychotherapeutic treatment, and their effectiveness - include any negative responses - history of past pharmacological treatment, its effectiveness and side-effects if applicable - include any negative responses - any other relevant information, including negative responses to salient clinical questions about past history of psychiatric symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **History of Present Concerns** [Write an introduction to the patient i.e name, gender, pronouns, job, marital status, where they are originally from, where they currently live, who they live with, whether they own or rent, and if they have children] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Provide a detailed description of the patient's primary mental health concerns and their impact on daily life. Include information about: - main symptoms and concerns leading to this appointment - patient's understanding of their symptoms and motivation for seeking treatment, if applicable. Explicitly mention if patient suspects any specific diagnosis. - duration/timing/location/quality/severity/context of main symptoms/presenting complaint - description of how the symptoms have changed or evolved - include a timeline if appropriate - any clear triggering or perpetuating factor - anything that worsens or alleviates the symptoms - how the symptoms affect the patient's daily life, work, and activities - any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes - current self-medication behaviors if applicable and their effectiveness - any coping mechanisms or support systems currently in place - any recent treatment/therapies tried for the main symptoms and their effectiveness - any salient negative responses to clinical questions - any other relevant information or concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Personality** [Describe details on personality characteristics, and any relevant features suggestive of maladaptive traits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Mental Status Examination** [Describe mental state examination including: - appearance, behaviour, eye contact and psychomotor activity - mood and affect - describe their subjective self-reported mood, and how this would translate objectively (i.e depressed, elated, anxious, dysphoric, etc) together with affect observed noting its congruence, reactivity and amplitude - speech & thought - describe speech by noting its rate, volume, coherence and organization, followed by describing the linked thought process psychopathology (coherence, logic, organization, etc). Formally exclude formal thought disorders if appropriate. Describe any queried thought content abnormalities, explicitly denying or confirming as appropriate delusions, overvalued ideas, obsessive ideas/intrusive thoughts, anxious ruminations, or any other relevant details - perception: if no hallucinations or any other perceptual disturbances are described, explicitly deny their presence or any behaviour suggestive of them if hallucinations or any other perceptual experiences are described - describe them thoroughly including modality, characteristics and insight related features, alongside frequency and duration. - describe patient's insight into their difficulties, their beliefs around their nature, their ability to recognize limitation, their help-seeking stance and their engagement with care.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Risk Assessment** [Describe risk to self including: - current thoughts of suicide and self-harm (passive and structured), intent or plan, or their denial/absence - history of self-harm, suicidal ideation, or attempts or its denial if applicable - other risk factors not mentioned above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Describe risk to others including: - current thoughts of harm to others or their denial/absence - history of violence or aggression, including towards others or property - other risk factors, regarding risk to others not mentioned above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Describe other risks - if applicable including: - risk of neglect - risk of unintended harm to self - risk of disengagement and/or non-compliance - risk/safeguarding concerns towards vulnerable adults - risk/safeguarding concerns towards children if none applicable just say "No other risks identified"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summarize risk, and elaborate on any relevant protective factors, such as coping skills, resilience, or support systems and crisis planning / safety plans or interventions currently in place] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Capacity Assessment** [Describe assessment of capacity or presumed capacity features, as applicable; if no formal capacity assessment can be identified cite reasoning behind why there were no reasons to doubt capacity.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Diagnosis, Impression and Discussion on Treatment Plan** Diagnosis: [Provide ICD-11 diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Provide a short summary that explains diagnosis rationale; if available mention what exactly was discussed in the later part of appointment, when the diagnosis was being explained by the clinician to the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summarize the discussion around treatment options and pathways, including all that was explored, and what was decided on. Include the rationale for the options chosen and rejected respectively] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Suggestions and Plans Discussed** (Use numbered list items to write the plan section below; use as many bullet points as you need to comprehensively capture all the suggestions and plans discussed during the appointment) [Describe agreed plan, including: - prescribed medications or changes to current medications - any psychotherapeutic treatment discussed and plan around it - lifestyle changes or habits to consider, including physical activity or exercise recommendations, mental health or stress management strategies, dietary recommendations or restrictions - any referrals to specialists or other healthcare providers - any diagnostic tests or procedures to be scheduled - further reading and/or psychoeducational resources recommended - any peer-support suggestions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Helpful resources: [List all resources appropriate and explicitly mentioned in the notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Always refer to the patient by their name, if available; only refer to them as "the patient" if there is no information about the patient's name in the patient details.) (Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc - use only the transcript, contextual notes or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)