Mental Health Counselor Template

Psychiatry Follow Up

A professional Mental Health Counselor template for healthcare professionals.

About this template

Need a clear and concise way to document your mental health sessions? This Psychiatry Follow Up template is perfect for mental health counselors. It provides a structured format to record essential information, including the patient's current struggles, mental status, diagnoses, medication adjustments, and treatment recommendations. This template helps you create comprehensive notes, ensuring all key aspects of the session are captured. Using this template with Heidi, the AI scribe, can streamline your documentation process, saving you time and allowing you to focus more on your clients. Easily generate detailed and accurate progress notes with this efficient tool.

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Clinical Update: On 1 November 2024, the patient presented for a follow-up session. The patient reported continued struggles with low mood and anxiety, particularly during social situations. They are currently taking Sertraline 100mg daily, which seems to be providing some relief, although the patient still experiences occasional panic attacks. Sleep has improved slightly, with the patient now averaging 6-7 hours of sleep per night. Self-care routines are inconsistent, and the patient admits to infrequent exercise. Social engagement remains limited, and the patient denies any substance use. The patient's mood is generally low, with frequent feelings of sadness and worry. Anxiety symptoms include racing thoughts and physical sensations such as a racing heart. No screening results for other psychiatric conditions were mentioned. Mental Status Exam: The patient was alert and cooperative during the session. Their mood was low, and their affect was constricted. Thought process was linear, and thought content revealed themes of worry and self-doubt. Speech was normal in rate and rhythm. No perceptual disturbances were reported. Cognitive function appeared intact. The patient demonstrated some insight into their condition but struggled with judgment in social situations. No suicidal ideation was expressed. Diagnostic Impression: Major Depressive Disorder, Moderate, and Generalised Anxiety Disorder. The primary diagnosis is based on the patient's persistent low mood, loss of interest, and excessive worry. Medication Recommendations: The current dosage of Sertraline 100mg daily will be maintained. The patient was advised to continue taking the medication as prescribed and to report any side effects. Additional Treatment Recommendations: The patient was encouraged to continue with their existing therapy sessions. A referral to a support group for anxiety was provided. Lifestyle and Self-Care: The patient was encouraged to establish a regular sleep schedule, incorporate daily exercise, and practice mindfulness techniques to manage anxiety. Patient Understanding and Agreement: The patient demonstrated a good understanding of their diagnoses and treatment plan and agreed to continue with the recommended interventions. Follow-Up: The patient is scheduled for a follow-up appointment in four weeks, via telehealth.

Clinical Update: [summarise the clinical encounter including the patient’s reported struggles, symptoms, medication use and effects, sleep, self-care, social engagement, substance use, mood and anxiety symptoms, and any screening results for other psychiatric conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Mental Status Exam: [document the patient’s mental status covering alertness, cooperation, mood, affect, thought process and content, speech, perceptual disturbances, cognitive function, insight and judgment, and suicidal ideation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Diagnostic Impression: [record current diagnoses and any differential diagnoses. Include reasoning for primary diagnosis if noted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Medication Recommendations: [describe any medication changes, additions, discontinuations or dosage adjustments, including instructions if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Additional Treatment Recommendations: [document any further clinical recommendations such as referrals, assessments, therapy suggestions or other interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Safety Planning: [outline any safety measures discussed including suicidal risk management, crisis planning or escalation protocols] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Lifestyle and Self-Care: [record any suggestions provided regarding lifestyle changes, routines, coping strategies or wellness planning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Patient Understanding and Agreement: [comment on patient’s level of understanding, questions asked, and agreement or disagreement with the proposed treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in full sentences in paragraph form.) Follow-Up: [record follow-up appointment details including timeframe, date, time, and format (in-person, telehealth, etc)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise 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.)

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