"Patient consented to AI scribe and Mental Health Care Plan"
"Aware of schedule of fees"
History of Presenting Complaint (HOPC):
* Mood: Low mood for the past 6 months.
* Anhedonia: Loss of interest in activities.
* Sleep: Difficulty sleeping, waking up early.
* Thoughts of guilt or worthlessness.
* Energy levels: Low energy levels.
* Suicidal thoughts: Occasional thoughts of suicide, no attempts.
The patient's symptoms have gradually worsened over the past six months. The low mood and anhedonia are persistent, and the sleep difficulties have become more frequent. The patient reports that the suicidal thoughts are fleeting but concerning.
The patient is experiencing significant stress due to financial difficulties and relationship problems.
Alcohol and Other Drugs (AOD):
* Drinks alcohol occasionally, about once a week.
* Smokes 10 cigarettes a day.
* No illicit drug use.
Psychiatric History:
* Major Depressive Disorder
* Anxiety Disorder
Medication and Allergies:
* No known allergies.
* Sertraline 50mg daily.
Social History:
* Renting a flat, lives alone.
* Single.
* Employed as a teacher.
Family History:
* Mother has a history of depression.
Impression:
Patient presents with symptoms consistent with Major Depressive Disorder and co-morbid Anxiety Disorder. Risk stratification is low to moderate, with suicidal ideation present but no active plans or attempts. Further assessment and intervention are required.
Plan:
* Continue Sertraline 50mg daily.
* Referral to a psychologist for Cognitive Behavioral Therapy (CBT).
* Encourage regular exercise and a healthy diet.
* Discussed the importance of social support and connecting with friends and family.
"Safety planning
1. Self-soothing (distraction techniques, breathing exercises, mindfulness or exercise)
2. Phone a friend (family, friends or partner)
3. Organisations (Lifeline 13 11 14, Samaritans 0863 839 850, MHERL 1300 555 788)
4. Go to ED"
"Patient consented to AI scribe and Mental Health Care Plan"
"Aware of schedule of fees"
History of Presenting Complaint (HOPC):
[list any psychiatric symptoms including mood, anhedonia, anxiety, intrusive thoughts, compulsions, sleep, appetite, thoughts of guilt or worthlessness, hallucinations, delusions, paranoia, energy levels, suicidal thoughts including history of any attempts, motivation levels if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[Describe the time course of any symptoms and whether they're getting better or worse] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single paragraph.)
[Describe any current psychosocial stressors] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single paragraph.)
Alcohol and Other Drugs (AOD):
[alcohol history] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
[smoking history] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
[use of any illicit drugs] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
Psychiatric History:
[list previous psychiatric diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[list any psychiatrists that the patient sees regularly] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single line.)
Medication and Allergies:
[list patient allergies] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[list current medications] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
Social History:
[Housing status e.g. owns or renting and who they live with] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
[Relationship status including name of spouse if applicable] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
[Names and ages of any children if applicable] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[Current employment status] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a single bullet point.)
Family History:
[list any family history of mental illness] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
Impression:
[differential diagnosis including risk stratification] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a paragraph of full sentences.)
Plan:
[recommended lifestyle changes] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[recommended medication changes] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
[any offers of referrals and whether they were accepted or not] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Write as a bullet point list.)
"Safety planning
1. Self-soothing (distraction techniques, breathing exercises, mindfulness or exercise)
2. Phone a friend (family, friends or partner)
3. Organisations (Lifeline 13 11 14, Samaritans 0863 839 850, MHERL 1300 555 788)
4. Go to ED"
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
