DVA Psychiatric Report
Referral Information:
123456789
John Smith
01/01/1970
History of Presenting Complaint:
Mr. Smith presents today for a psychiatric assessment related to his service in the Australian Defence Force. He reports experiencing persistent low mood, anxiety, and difficulty sleeping since returning from deployment. He is struggling to cope with daily activities and is seeking support to manage his symptoms.
Detailed description of the workplace or service-related injury, including mechanism, severity, impact on work, investigations, treatment, follow-up, and functional impact. Present chronologically if possible, and include verbatim descriptions where available.
Mr. Smith was involved in a motor vehicle accident during his deployment in Afghanistan in 2005. He sustained a head injury and was diagnosed with a concussion. He was treated with rest and pain medication. He reports ongoing headaches, memory problems, and difficulty concentrating since the accident. He was medically discharged from the army in 2006.
Current Psychiatric Status:
Mood – Mr. Smith reports feeling persistently sad, hopeless, and irritable.
Anxiety – He experiences frequent worry, restlessness, and panic attacks.
Sleep – He has difficulty falling asleep and staying asleep, with frequent nightmares.
Energy levels – He reports feeling fatigued and lacking energy.
Motivation – He has lost interest in activities he used to enjoy.
Appetite and weight – His appetite has decreased, and he has lost 5 kg in the last 6 months.
Memory and concentration – He reports difficulty with memory and concentration.
Anger – He experiences frequent outbursts of anger and irritability.
Social and leisure activities – He has withdrawn from social activities and spends most of his time alone.
Relationships – His relationships with his family have become strained.
Self-esteem and confidence – He feels worthless and lacks confidence.
Mobility and living skills – He is independent in his daily living activities.
Past Psychiatric History:
Mr. Smith was seen by a psychologist for 6 months in 2010 for symptoms of depression and anxiety. He reports that the therapy was helpful at the time, but his symptoms have returned.
Substance Use History:
Mr. Smith reports smoking 10 cigarettes per day. He drinks alcohol occasionally, but denies any substance use disorder.
Psychosocial and Developmental History:
Mr. Smith had a normal birth and developmental milestones. He grew up in a supportive family environment. He reports a history of childhood trauma.
Educational History:
Mr. Smith completed high school.
Occupational History:
Mr. Smith worked as a mechanic before enlisting in the army. He was medically discharged in 2006.
Military History:
Mr. Smith enlisted in the Australian Defence Force in 2000. He served in Afghanistan in 2005. He was medically discharged in 2006.
Family Psychiatric History:
Mr. Smith's mother has a history of depression.
Forensic History:
Mr. Smith has no forensic history.
Past Medical History:
Mr. Smith has a history of concussion and chronic pain.
Medication:
Mr. Smith is currently taking paroxetine 20mg daily.
Allergies:
Mr. Smith has no known allergies.
Social History:
Mr. Smith is 54 years old, lives alone, and is unemployed. He receives a disability pension. He has limited social support.
Mental Status Examination:
- Appearance: Mr. Smith appears his stated age, is well-groomed, and is dressed in casual clothing.
- Behaviour: Mr. Smith is cooperative and displays psychomotor retardation.
- Speech: His speech is slow and monotone.
- Mood: Mr. Smith reports feeling sad.
- Affect: His affect is constricted.
- Thoughts: He reports negative thoughts about himself and the future.
- Perceptions: He denies any hallucinations or perceptual disturbances.
- Cognition: He is oriented to person, place, and time. His memory is impaired.
- Insight: He has some insight into his condition.
- Judgment: His judgment appears to be impaired.
Stressful Events:
Mr. Smith reports experiencing significant stress related to his military service, including combat exposure and the death of a close friend.
Provisional Diagnosis:
Major Depressive Disorder, Recurrent, Moderate, and Posttraumatic Stress Disorder. The patient meets the DSM-5 criteria for both disorders. He reports persistent low mood, loss of interest, sleep disturbance, and difficulty concentrating, meeting the criteria for Major Depressive Disorder. He also reports intrusive memories, avoidance behaviours, and hyperarousal, meeting the criteria for Posttraumatic Stress Disorder.
Causal Factors:
The patient's psychiatric conditions are likely caused by a combination of factors, including his military service, combat exposure, and the motor vehicle accident. His childhood trauma may have also increased his vulnerability to developing these conditions.
Treatment and Prognosis:
With appropriate treatment, including medication and psychotherapy, Mr. Smith's prognosis is guarded. He may experience improvement in his symptoms, but complete remission is unlikely.
Risk Assessment:
Mr. Smith denies any current suicidal or homicidal ideation. He does not pose a risk to himself or others.
Conclusion:
Mr. Smith presents with symptoms of Major Depressive Disorder and Posttraumatic Stress Disorder. His conditions are likely related to his military service and childhood trauma. He requires ongoing psychiatric care.
Recommendations:
Continue paroxetine 20mg daily. Refer to a psychologist for cognitive behavioural therapy for PTSD. Consider referral to a pain management specialist. Follow-up in 4 weeks.
DVA Psychiatric Report
Referral Information:
[DVA file number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Veteran’s name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Veteran’s date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
History of Presenting Complaint:
[Current issues, reasons for visit, discussion topics, and presenting complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
[Detailed description of the workplace or service-related injury, including mechanism, severity, impact on work, investigations, treatment, follow-up, and functional impact. Present chronologically if possible, and include verbatim descriptions where available.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Current Psychiatric Status:
Mood – [Mood symptoms and descriptions as narrated by patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Anxiety – [Anxiety symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Sleep – [Sleep patterns and disturbances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Energy levels – [Energy complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Motivation – [Motivational changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Appetite and weight – [Appetite and weight changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Memory and concentration – [Cognitive issues described] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Anger – [Anger or irritability issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Social and leisure activities – [Participation or withdrawal from social/leisure activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Relationships – [Quality of relationships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Self-esteem and confidence – [Comments on self-worth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Mobility and living skills – [Description of independence and living abilities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Past Psychiatric History:
[Past psychiatric treatments, admissions, psychologist sessions, therapy duration, and outcomes with dates if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Substance Use History:
[History of smoking, alcohol use, and drug use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Psychosocial and Developmental History:
[Developmental history including birth, milestones, upbringing, attachment, speech or motor delays, and schooling] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Educational History:
[Level of education achieved, including school completion year, university/trade/TAFE courses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Occupational History:
[Occupational history including workplaces, job roles, durations, reasons for leaving] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Military History:
[Military enlistment, service history, deployments, discharge date, and ranks held] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Family Psychiatric History:
[Family history of psychiatric conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Forensic History:
[Forensic history including charges, arrests, prison sentences, or legal matters] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Past Medical History:
[Past medical history including diagnoses and surgeries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Medication:
[Current and past medications including doses, frequency, and herbal supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Allergies:
[Known allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Social History:
[Social history including age, living situation, employment status, benefits, and social supports] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Mental Status Examination:
- Appearance: [Clothing, hygiene, physical features] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Behaviour: [Interaction, activity level, unusual behaviours] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Speech: [Rate, clarity, coherence, tone] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Mood: [Self-described mood] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Affect: [Observed affect] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Thoughts: [Thought process/content] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Perceptions: [Hallucinations or perceptual disturbances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Cognition: [Memory, orientation, comprehension] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Insight: [Level of awareness of condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Judgment: [Decision-making capacity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Stressful Events:
[Details of stressful events before, during, or after service] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Provisional Diagnosis:
[Detailed note on provisional diagnosis and DSM-5 criteria, including examples of how criteria are met] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[All formal diagnoses made] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Differential diagnoses considered with DSM-5 criteria justification] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Causal Factors:
[Detailed note on causation of the psychiatric condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Treatment and Prognosis:
[Detailed note on treatment recommendations and prognosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Risk Assessment:
[Assessment of suicidality, homicidality, aggression, vulnerability, and other risks] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Conclusion:
[Summary of conclusions and opinions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Recommendations:
[Recommendations and treatment plan including medication changes, psychological support, and other interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care plan – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned, leave it blank or omit that section entirely. Always write numbers in digits, not words. Write in paragraph format unless bullet points are explicitly requested.)
