"Patient gives consent to use AI-scribe during the session."
PRESENTATION:
* Reports feeling increasingly anxious over the past week.
* Difficulty sleeping, experiencing racing thoughts at night.
* Reports feeling overwhelmed by work-related stress.
GENERAL ISSUES:
* Reports no significant physical health concerns.
* Sleep: Difficulty falling asleep, waking up frequently during the night. Appetite: Reduced appetite due to anxiety.
* Denies alcohol or substance use.
* Work-related stress, feeling pressure to meet deadlines. Strained relationship with a colleague.
CURRENT MEDICATIONS AND TREATMENTS AND SUPPORTS:
* Currently taking Sertraline 50mg daily, prescribed by GP. Adherence is good.
* Attending weekly Cognitive Behavioural Therapy (CBT) sessions.
MSE:
* Appearance: Well-groomed, appropriate for age.
* Behaviour: Restless, fidgeting.
* Speech: Normal rate and rhythm, slightly pressured.
* Mood: Anxious.
* Affect: Anxious, congruent with mood.
* Thought process: Racing thoughts, some difficulty concentrating.
* Thought content: Worries about work and relationships.
* Perception: No hallucinations or delusions reported.
* Cognition: Oriented to time, place, and person.
* Insight: Aware of anxiety and its impact.
* Judgment: Appears intact.
RISKS:
* Reports feeling overwhelmed but denies any current suicidal ideation or self-harm thoughts.
IMPRESSION:
* Patient presents with increased anxiety symptoms, likely related to work and relationship stressors.
* Anxiety symptoms have worsened since the last session.
* Contributing factors include work pressure and interpersonal difficulties.
MANAGEMENT PLAN:
1. Continue CBT sessions to address anxiety symptoms.
2. Explore and implement relaxation techniques, such as deep breathing exercises.
3. Encourage patient to discuss work-related stressors with their manager.
Investigations:
* No investigations planned at this time.
Medications:
* Continue Sertraline 50mg daily.
Psychological treatments:
* Continue weekly CBT sessions.
Other:
* Encourage regular exercise and a healthy diet.
Review:
* Schedule a follow-up session in two weeks to assess progress and adjust the treatment plan as needed.
Communication with others:
* No communication with others planned at this time.
"Patient gives consent to use AI-scribe during the session."
PRESENTATION:
[document the patient's chief complaint, symptoms, presenting problems, or the primary reason for the current encounter, including any changes, progress or deterioration of the situation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points. Omit conversational filler words such as "yeah", "really", "um", "like".)
GENERAL ISSUES:
[describe current physical health and any ailments and physical disorders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[describe sleep and appetite] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[describe any alcohol and psychoactive substance use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[mention any background issues related to work, family, relationship and studies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
CURRENT MEDICATIONS AND TREATMENTS AND SUPPORTS:
[list all current medications including prescription, OTC, and herbal supplements with dosage, frequency, and adherence] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[describe any psychological therapies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
MSE:
[document the patient's mental state examination findings including appearance, behaviour, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points without subheadings.)
RISKS:
[identify and describe any significant risks to the patient or others, such as self-harm, suicide, aggression, safeguarding concerns, or other safety considerations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
IMPRESSION:
[provide a concise summary of the clinical formulation, including changes such as improvements or deterioration since last encounter, and contributing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
MANAGEMENT PLAN:
(Write as a numbered list.)
Investigations:
[detail any planned investigations, such as laboratory tests, imaging, or psychological assessments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Medications:
[document all medications and outline any medication changes, new prescriptions, or adjustments to existing medication regimens, including rationale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Psychological treatments:
[describe any psychological therapies and interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Other:
[include any other non-pharmacological or non-psychological interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Review:
[specify the plan for follow-up, including the timeframe for the next review and what aspects will be monitored] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Communication with others:
[document any planned communication such as with General Practitioner] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included 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, depending on the format, as needed to capture all the relevant information from the transcript.)
(Omit patient's or clinician's conversational quotes, comments, and filler words such as "yeah", "really", "um", "like", "you know" from the output.)
