Difficulty obtaining history:
[Describe any difficulties obtaining history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Reliability of information:
[Describe reliability of information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Demographics:
Name: [Patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Age: [Patient age] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Language: [Language spoken] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Marital Status: [Describe marital status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Children: [Number and details of children] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Employment status: [Describe employment status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
- Disability grant / Pension / Medical boarding: [Record if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Accommodation: [Location, Formal/Informal, Number of residents] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Religion: [Describe religion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Handedness: [Right/Left handed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Context of assessment: [Inpatient / Outpatient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Route of referral: [Describe referral route] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
MHCA status: [Describe status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting Complaint:
Verbatim presenting concern: [Record presenting concern in patient’s words] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
History of Presenting Complaint:
Onset: [Describe onset] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Precipitant/s: [Describe precipitating factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Temporal relation to precipitant/s: [Describe relation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Duration: [Describe duration] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Evolution: [Describe evolution] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Aggravating/Relieving factors: [Describe factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Associated symptoms:
- Medical: [Describe symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
- Psychiatric (DSM screening): [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Response to treatment: [Describe response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Systematic enquiry: [Mood cluster / Anxiety cluster / Psychotic cluster / Eating and feeding cluster / Cognitive / Personality] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Psychiatric History:
First episode: [Describe details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
First point of contact: [PCP, psychiatry, traditional healer, etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnoses: [List diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Episode history: [Describe precipitants, duration, severity, response, remission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Admissions: [Number, MHCA status, duration, treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past pharmacological, psychological, and social interventions: [Describe and record response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ECT: [Number, response, side effects] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Rehabilitation: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Adherence: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past suicide attempts/self-harm: [Details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical and Surgical History:
Neurological: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other Medical: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Gynae/Obstetric: [Contraception, LMP, pregnancies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Surgeries: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past/Current treatments: [Side effects, adherence] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Drug and Alcohol History:
Cigarettes: [Onset, amount, duration, cessation attempts] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Alcohol: [Onset, amount, pattern, complications, cessation, remission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other drugs: [Specify and detail] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Caffeine: [Amount, duration] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
OTC medications: [Details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Forensic History:
Cautions/Charges/Convictions: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Sentences: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Pending cases: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Antisocial behaviour screen: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Family History:
Genogram summary: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Deaths: [Age, cause] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Medical illness: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Psychiatric illness: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Relationships and attachment quality: [Describe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Personal History:
Developmental: [Pregnancy, antenatal/postnatal period, delivery, milestones, illness/trauma, abuse, parental separation, etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Educational: [Grade 1 age, type of schooling, difficulties, protective factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Occupational: [Job history, issues, reasons for termination, grants] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Psychosexual/Relationships: [Status, quality, domestic violence, trauma, orientation, contraception, STIs, pregnancies, children] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Current Social Circumstances: [Housing, employment, ADLs/IADLs, support, finances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Premorbid Personality: [Self-description, interests, coping, stress response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise 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 for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; 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.)
