Key findings from last session:
- Patient reported experiencing increased anxiety levels, particularly in social settings.
- Noted improvement in sleep patterns with the introduction of a nightly routine.
Subjective:
- The patient is visiting to address ongoing anxiety issues, particularly in social situations.
- Symptoms have been present for approximately 6 months, with increased severity over the past 2 months.
- The patient reports that deep breathing exercises have provided some relief, but symptoms persist.
- Symptoms have worsened over time, with more frequent episodes of anxiety.
- Previous episodes of anxiety were managed with cognitive behavioral therapy, which was partially effective.
- The anxiety significantly impacts the patient's ability to participate in social activities and affects work performance.
- Associated symptoms include occasional heart palpitations and sweating during anxiety episodes.
Objective:
- Vitals signs: Blood pressure 120/80 mmHg, heart rate 78 bpm.
- Mental state examination: Patient appears anxious, with a tense posture and fidgeting.
Assessment:
- Likely diagnosis: Generalized Anxiety Disorder.
- Differential diagnosis: Social Anxiety Disorder.
Plan:
- Investigations planned: None at this time.
- Treatment planned: Continue with cognitive behavioral therapy sessions weekly.
- Relevant other actions: Referral to a psychiatrist for medication evaluation.
(If previous session findings, or any additional information is supplied in the context tab or discussed, draw comparisons and flag any significant differences in the patientβs presentation eg. changes in key symptoms. Additionally, populate the βkey findings from last sessionβsection in this note using the information in the context tab.)
Key findings from last session: [Bullet point list of key previous findings using information in context tab or discussed as part of the session.]
Subjective:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Assessment:
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(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 include in your note.)
