Mental State Review (Generic)

**Mental Health Review** [Client name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) [Date of review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use format DD/MM/YYYY.) Clinician: [Clinician name and role/title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Location: [Location of consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify clinic, phone, video, or home visit.) **Presenting status** [Summary of client's current mental state] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in brief paragraphs of full sentences.) [Recent changes in wellbeing] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in brief paragraphs of full sentences.) [Reason for review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Include only clinically relevant information such as routine review, relapse, medication review, or risk concern. Write in brief paragraphs of full sentences.) **Mood and emotional state** Low mood: [Presence, severity, duration, and triggers of low mood] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Anxiety: [Presence, type, frequency, avoidance behaviours, or panic symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Irritability or agitation: [Presence and description of irritability or agitation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Anhedonia: [Presence of loss of interest or pleasure in activities] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Hopelessness or helplessness: [Presence and description of feelings of hopelessness or helplessness, including any references to self-harm, risk to self or others, safeguarding concerns, or suicidality] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description highlighting any risk factors.) **Psychotic symptoms** Hallucinations: [Presence, type, frequency, and level of distress caused by hallucinations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Delusions or paranoid thoughts: [Presence, content, and level of conviction regarding delusions or paranoid thoughts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Thought disorder: [Presence and description of thought disorder including coherence, flow, and form of thoughts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Insight: [Level of insight] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify intact, partial, or absent.) **Suicidality and self-harm** Thoughts of death: [Presence and nature of thoughts of death, whether passive or active] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Suicidal ideation: [Presence, frequency, intensity, and any plans regarding suicidal ideation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Suicide attempts: [Recent or historic suicide attempts including method, intent, and any medical treatment received] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Self-harm: [Type, frequency, and function of self-harm behaviours] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Protective factors: [Protective factors including family, faith, goals, hope, and engagement with services] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief bullet points.) Risk management plan updated: [Whether risk management plan has been updated] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify yes or no.) **Functioning** [Summary of impact of patient's difficulties on overall functioning across multiple areas] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in brief paragraphs of full sentences.) Daily activities: [Impact on sleeping, eating, hygiene, and ability to complete tasks] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) School/work attendance: [Pattern of school or work attendance and reason for any reduction or absence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify consistent, reduced, or absent with reason.) Social functioning: [Description of social functioning including withdrawal, social anxiety, or active engagement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Coping strategies: [Description of healthy and unhealthy coping strategies including any substance use, distraction techniques, or routines] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) [CGAS score and justification based on functioning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Suggest relevant score based on literature on CGAS.) **Sleep and appetite** Sleep: [Sleep pattern including whether normal, reduced, increased, or fragmented, and any issues with onset or maintenance] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Appetite: [Appetite pattern including whether increased, reduced, or unchanged, and any weight changes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Energy levels: [Energy levels including whether normal, fatigued, or overactive] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) **Medication** Current medication(s): [List of current medications with doses and frequency] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list.) Adherence: [Medication adherence pattern] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify consistent, inconsistent, or declined.) Side effects: [Any side effects experienced including sedation, weight change, gastrointestinal issues, or extrapyramidal symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Effectiveness: [Perceived benefit and tolerability of medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Recent changes: [Any recent medication changes including initiations, adjustments, or discontinuations with reasons] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) **Substance use** Alcohol: [Alcohol use including frequency, amount, and impact on functioning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Drugs: [Drug use including type, frequency, context of use, and any features of dependence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Smoking/vaping: [Smoking or vaping habits including frequency and motivation to reduce] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) **Physical health** Known conditions: [Known physical health conditions including asthma, epilepsy, diabetes, or other relevant conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief list.) Physical health review: [Physical health review findings including weight, blood pressure, and any blood tests completed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Coordination with GP or specialists: [Details of any coordination with GP or specialist services] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) **Risk assessment** Risk to self: [Assessment of risk to self with level] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify low, moderate, or high with justification.) Risk to others: [Assessment of any risk to others] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.) Safeguarding concerns: [Any safeguarding concerns and whether active plan is in place] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Specify yes or no with details.) Summary of current risk and protective factors: [Summary of current risk factors and protective factors including recent stressors and support network] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief bullet points.) **Plan and recommendations** Interventions: [Planned interventions including therapy, medication, monitoring, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief bullet points.) Safety: [Safety planning including updated safety plan, increased frequency of contact, or crisis plan review] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief bullet points.) Liaison: [Any liaison with GP, school, social worker, or other professionals including whether contacted or to be contacted] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief bullet points.) Follow-up: [Next review timeframe and purpose] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as brief description.)