Psychiatric Follow-Up Letter

(Refer to the patient by their first name. Make all headings bold.) **[PATIENT'S FULL NAME] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), DOB [PATIENT'S DATE OF BIRTH] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [PATIENT'S MEDICAL RECORD NUMBER] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [PATIENT'S ADDRESS] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [PATIENT'S EMAIL ADDRESS] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [PATIENT'S TELEPHONE NUMBER] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)** (Write all on one line with no line breaks, in bold and all caps.) **Diagnosis:** [Psychiatric diagnoses, taken from previous letters unless changes are discussed during the session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a bulleted list. Do not invent or infer a diagnosis.) [Current medical diagnoses, taken from previous letters unless changes are discussed during the session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a bulleted list. Do not invent or infer a diagnosis.) **Current Medications:** [Current medications including names and doses, taken from previous letters unless changes are discussed during the session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a bulleted list.) **Update on psychiatric issues** [Update on the patient's current psychiatric issues](Only include if explicitly mentioned in the transcript, else omit section entirely. Do not use information from contextual notes. Write in full sentences and paragraph format.) **Update on medical issues** [Update on the patient's current medical issues](Only include if explicitly mentioned in the transcript, else omit section entirely. Do not use information from contextual notes. Write in full sentences and paragraph format. **Update on medications** [Update on the patient's current medications, including any changes, tolerability, or concerns](Only include if explicitly mentioned in the transcript, else omit section entirely. Do not use information from contextual notes. Write in full sentences and paragraph format.) **RISK** [Risk of harm to self, including any suicidal ideation, self-harm, or related history](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) [Risk of harm to others, including any history or current concerns regarding violence or aggression](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) **RECOMMENDATIONS** [Plan for medications](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Number each point. Each point starts on a new line. Do not use quotes.) [Plan for psychological therapy](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Number each point. Each point starts on a new line. Do not use quotes.) [Any other treatment plan or recommendation](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Number each point. Each point starts on a new line. Do not use quotes. If the recommendation is directed at another person such as the GP, phrase it as "Can I ask [addressee name or profession] to please [request]?" and format that line in bold.) [Follow-up appointment date, time, and place](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Number each point. Each point starts on a new line. If the patient is not receiving follow-up, write "Discharged from this clinic.") "If you are feeling overwhelmed or suicidal, 24h crisis counselling is available from the Samaritans on 116 123 or advice from NHS 111 (option 2). If you are feeling unsafe, mental health support is available in every UK emergency department or via ambulance (999)." **COPY TO:** [Patient's GP name and address](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Include GP email address if available. If the GP address is the same as the patient's address, write "GP - UNKNOWN") [Any other copy recipients, including the referrer if known and any other individuals mentioned during the session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)