Relapse or Crisis Encounter Note

Relapse or Crisis Encounter Note Date and Nature of Presentation: [record date and time of encounter and describe the acute event prompting review (e.g. substance relapse, overdose, intoxication, acute withdrawal, psychiatric decompensation, violent or unsafe behaviour); include mode of presentation if mentioned (e.g. self-presented, EMS, SAPS, family, clinic referral)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Substance Use: [document substances reportedly used or observed (e.g. alcohol, cannabis/dagga, methamphetamine/tik, nyaope, opioids, benzodiazepines), timing of last use, quantity if described, route of use, triggers or precipitating factors, and relevant contextual factors (e.g. stressors, social environment)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Risk Factors: [record any identified risks including suicidality or suicidal ideation, recent attempts, overdose risk, severe withdrawal, aggression or violence, psychosis, impaired judgement, safeguarding concerns, homelessness, or risk to others] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Mental State: [document observed or reported mental state at the time of contact, including appearance, behaviour, level of consciousness, mood, affect, thought content (e.g. paranoia, hallucinations), insight, judgement, and orientation] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Immediate Interventions: [list any immediate actions taken such as medical stabilisation, medication administration or changes, withdrawal management, brief counselling, safety planning, involvement of family, referral to emergency services, admission, or engagement with social work or SAPS] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) Plan and Follow-Up: [record agreed next steps including referral to emergency department, inpatient admission, detox or rehabilitation services (public or private), community clinic follow-up, NGO or outreach referral, harm reduction measures, and timing or location of planned re-evaluation] (Only include if explicitly mentioned in transcript, contextual note or clinical note; otherwise, omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output; just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)