1 November 2024
Re: Sarah Jones - Depression
Thank you for referring Sarah to me for assessment and management. Sarah is 32 years old, employed as a teacher, and is married to John, aged 35. They have one child, Emily, aged 5.
Sarah presented with symptoms of low mood, anhedonia, and changes in appetite and sleep. She reported feeling overwhelmed by work and family responsibilities. She has a history of similar episodes, but this is the most severe and prolonged.
Plan:
- Initiate a course of sertraline 50mg daily.
- Schedule weekly psychotherapy sessions.
- Arrange a follow-up appointment in four weeks to assess progress.
Should you have any further questions regarding the above patient, please do not hesitate to contact me.
[Today's Date](Insert today's date)
Re: [Patient's Name] - [Reason for referral]
Thank you for referring [Patient's first Name] to me for assessment and management. [Note the patient's age, career, whether employed, married/single/separated or divorced, spouse/partner name, age, any children and their names and ages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Provide a summary/formulation of the healthcare encounter, including the most pertinent findings and information from the session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List the key symptoms elicited in the healthcare encounter supporting their diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [Detail the first key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Detail the second key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Detail the third key point of the plan] (be brief, only include if explicitly mentioned in the transcript or note. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Should you have any further questions regarding the above patient, please do not hesitate to contact me.
(For each section, only include if explicitly mentioned in transcript or context, else 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.)