Telehealth appointment date:
1 November 2024
Present:
Dr. Thomas Kelly, [Patient Name], and [Parent/Guardian Name]
Diagnoses/problem list:
* Major Depressive Disorder, recurrent, moderate severity
* Generalised Anxiety Disorder
* ADHD, combined presentation
Current medications:
* Sertraline 100mg daily
* Methylphenidate 20mg twice daily
Previous medications:
* Fluoxetine - ceased due to side effects of nausea and insomnia.
* Venlafaxine - ceased due to lack of efficacy.
Current supports:
* Weekly therapy with Dr. Sarah Jones, Psychologist.
* School counsellor, [School Name], meeting monthly.
* Parental support from [Parent/Guardian Name].
Objective:
* Weight: 65kg, Height: 160cm, BMI: 25.4
Summary:
"[Patient Name]" was reviewed by telehealth with [Parent/Guardian Name] present for a follow-up appointment regarding mood and ADHD symptoms.
Last appointment was on 1st October 2024. Since then, there has been a slight improvement in mood, with fewer depressive episodes. ADHD symptoms remain a significant challenge.
Patient reports improved mood and reduced anxiety symptoms since the last review. There has been a slight improvement in concentration, but still struggles with impulsivity and hyperactivity.
ADHD symptoms include inattention, hyperactivity, and impulsivity. Methylphenidate has shown some benefit, but the dose may need to be adjusted.
No major side effects were reported.
Patient reports difficulty with completing homework assignments and social interactions. These challenges were discussed, and strategies were reviewed.
Mental state examination:
Engagement: Cooperative and engaged.
Appearance: Appropriate for age.
Behaviour: Restless, fidgeting.
Speech: Normal rate and rhythm.
Mood: Elevated, but with some lability.
Affect: Congruent with mood.
Thought process: Linear and goal-directed.
Thought content: No suicidal ideation or homicidal ideation.
Perception: No hallucinations or delusions.
Insight: Aware of symptoms.
Judgement: Good.
Cognition: Intact.
Impression:
[Patient Name] presents with a complex presentation of Major Depressive Disorder, Generalised Anxiety Disorder, and ADHD, combined presentation. DSM-5 criteria are met for all diagnoses. The patient's symptoms significantly impact daily functioning, particularly in academic and social settings. The patient demonstrates strengths in their willingness to engage in therapy and adhere to medication regimens.
Differential diagnoses include Bipolar Disorder, which was ruled out based on the absence of manic episodes.
Symptoms significantly impact daily functioning, particularly in academic and social settings.
Overall functioning is moderate, with a guarded prognosis. The patient demonstrates strengths in their willingness to engage in therapy and adhere to medication regimens.
There were no immediate risks identified.
Today we discussed:
* Review of current medications and potential dose adjustments.
* Continued therapy with Dr. Jones.
* Strategies for managing ADHD symptoms at school and home.
Recommendations for GP:
* Please continue to monitor the patient's mood and ADHD symptoms.
* Please consider a referral to an occupational therapist for further support.
Recommendations for patient:
1. Continue taking Sertraline and Methylphenidate as prescribed.
2. Continue attending therapy sessions with Dr. Jones.
3. Implement strategies for managing ADHD symptoms, such as using a planner and breaking down tasks.
Please contact reception@pandionhealth.com.au if you require any clarification or assistance.
Telehealth appointment date:
[Date of appointment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Present:
[List of participants present during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnoses/problem list:
[Dot-point list of diagnoses discussed, including DSM-5 specifiers such as severity if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Current medications:
[Dot-point list of current medications] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Previous medications:
[Dot-point list of previous medications trialled, including reasons for ceasing each] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Current supports:
[Dot-point list of current supports including other clinicians, school counsellors, psychologists, family members] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(For professional supports, if mentioned, detail frequency of appointments and type of therapy.)
(If funding support is in place, such as NDIS, include this.)
Objective:
- [Vital signs such as heart rate, blood pressure, weight, and height] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Completed investigations and their results] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Planned investigations should be documented under Plan.)
- [Collateral history provided by professionals such as psychologists, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Summary:
"[Patient name]" was reviewed by telehealth [Include whether parent/guardian was present] for [Reasons for appointment]. (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[If this is a follow-up, include date of last appointment and relevant changes since then.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Summarise the appointment in past tense, including changes in mental state, current symptoms, relevant negative symptoms, recent social or occupational functioning, changes in treatment, current mood, treatment response, and any noted side effects.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Include any specific ADHD symptoms and treatment response if discussed.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Describe any negative medication side effects. If no side effects reported, state “no major side effects were reported.”] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Identify and describe any patient challenges or concerns and how these were addressed.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Mental state examination:
[Detailed psychiatric mental state examination written in prose, including engagement, appearance, behaviour, speech, mood, affect, thought process and content, perception, insight, judgement, cognition, and relevant negatives] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Use professional, clinical language.)
Impression:
[Detailed biopsychosocial formulation referencing presenting complaints, social and psychological factors, relevant diagnostic impression, and whether DSM-5 criteria are met. Mention important symptoms that are absent if relevant.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Relevant differential diagnoses, with comments on presence or absence of supporting symptoms.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Comment on the impact of symptoms on daily functioning and interpersonal relationships.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Include comments on overall functioning, prognosis, and patient strengths.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
[Comment on risks of harm to self or others. If not mentioned, state “There were no immediate risks identified.”] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Today we discussed:
[List in dot points any treatment planning discussions and decisions made with the patient.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Recommendations for GP:
[If recommendations are made, list them in cordial, clinical language. If none mentioned, write "Nil."] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Recommendations for patient:
1. [Treatment recommendation 1]
2. [Treatment recommendation 2]
3. [Treatment recommendation 3]
(Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Include evidence base and potential benefits where applicable. Use "please" when making a request.)
Please contact reception@pandionhealth.com.au if you require any clarification or assistance.
(Never create or assume patient details, symptoms, assessment, or treatment plans. Only include content that is explicitly mentioned in the transcript, contextual notes, or clinical note. If any information has not been explicitly mentioned, omit the relevant placeholder entirely. Use as many lines, bullet points, or paragraphs as necessary to accurately capture all details.)
