Scribe BC - ED Psych Note

**ID:** - John Smith, 32-year-old male **CC:** - Suicidal ideation **HPI:** - The patient presents to the emergency department with suicidal ideation. He reports feeling overwhelmed by work stress and relationship problems. He denies any current plans or intent to harm himself but admits to passive suicidal thoughts. He reports feeling down for the past week. He denies any substance use. Reports no previous psychiatric history. **PMHX:** - none **MEDS:** - none **ALLERGIES:** - NKDA **FAMILY HISTORY:** - Father with history of depression. **SOCIAL HX:** - Smokes 10 cigarettes per day. Drinks alcohol socially. **PHYSICAL EXAM:** - General appearance: Appears stated age, well-groomed. - Vital signs: BP 130/80, HR 88, RR 16, SpO2 98% on room air, Temp 37.0 C - Mental Status Examination: - Appearance: Well-groomed, appropriate for age. - Behaviour: Cooperative and calm. - Speech: Normal rate and rhythm, clear and coherent. - Mood: Reports feeling down. - Affect: Appropriate and congruent. - Thoughts: No active suicidal ideation or homicidal ideation. No current plan or intent. Denies any command hallucinations. - Perceptions: No hallucinations. - Cognition: Oriented to person, place, and time. Intact memory and concentration. - Insight: Aware of his current emotional state. - Judgment: Good. **INVESTIGATIONS:** - CBC, CMP, UA ordered and pending. **IMPRESSION / PLAN:** - Impression: Major Depressive Disorder, rule out suicidal ideation. - Plan: 1. Administer the Columbia-Suicide Severity Rating Scale (C-SSRS). 2. Initiate a psychiatric consultation. 3. Discussed safety plan with the patient. 4. Patient to be placed on 1:1 observation. 5. Patient to be admitted to the psychiatric unit for further evaluation and treatment. - Referrals: Psychiatric consultation completed. - Discharge Criteria: Patient will be discharged when suicidal ideation resolves and a safe discharge plan is in place. - Reasons to return to the emergency department: Worsening of suicidal ideation, development of a suicide plan, or any new concerning symptoms. "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks"