Summary:
- [Provide a brief summary of the patient’s presentation, current inpatient treatment, and progress] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [List key strengths, challenges, and treatment goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Chief Complaint:
- [State the patient’s primary reason for admission or presenting issue(s)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of Present Illness (HPI): (write this in a narrative paragraph format, use full sentences)
- [Describe the onset, duration, and progression of symptoms leading to inpatient admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Include any triggers, recent life events, or stressors contributing to symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Document any prior attempts at treatment or symptom management] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Psychiatric History:
- [Include previous diagnoses, treatments, hospitalizations, and response to care] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Document history of self-harm, suicidality, or other psychiatric events] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications:
- Current Medications: [List all prescribed medications, including doses and purposes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Possessed Medications: [List medications brought by the patient to the facility, if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Medication Access: [Document challenges accessing medications prior to admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Inpatient Medications:
- PRN: [Include as-needed medications prescribed and administered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- STAT: [Document any emergency/urgent medications given] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Medication Refusal: [Note any instances where the patient refused prescribed medications and reasons if known] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Substance Use:
- [Document the patient’s alcohol, tobacco, and recreational drug use, including frequency and duration] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Cravings/Withdrawal: [Include any reported cravings or withdrawal symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Pain History:
- [Include any chronic or acute pain history reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Drug Screen Result:
- [List results of any drug screens performed upon admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History:
- [Describe living situation, relationships, support system, and relevant social factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family History:
- [Document family history of psychiatric, medical, or substance use disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Legal History (Guardianship, Conservatorship, Representation, etc.):
- [Include details on legal guardianship, conservatorship, or representation, if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Document any history of legal issues or involvement with the criminal justice system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Trauma/Abuse History:
- [Describe any history of physical, emotional, or sexual abuse, as reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Document protective factors or ongoing trauma concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sleep:
- [Include details of sleep quality, duration, and disturbances] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Functioning Status:
- [Describe patient’s ability to perform activities of daily living (ADLs) and social functioning] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Disposition:
- [Document the patient’s emotional state, insight, and motivation regarding their treatment plan and discharge goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Aggression:
- [Include any instances of aggression or hostility, if observed or reported] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Review of Systems (ROS):
- ADHD: [Document symptoms consistent with ADHD] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Anti-Sociality: [Include behavioral concerns or traits associated with antisocial tendencies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Anxiety: [Document symptoms such as restlessness, worry, or panic attacks] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Autism: [Include observations or patient history consistent with autism spectrum disorder] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Depression: [Document symptoms such as low mood, hopelessness, or anhedonia] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Eating Disorder: [Include disordered eating behaviors, if observed or reported] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Mania: [Document symptoms such as elevated mood, impulsivity, or reduced need for sleep] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- OCD: [Include obsessive thoughts or compulsive behaviors, if present] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Personality Disorder: [Document traits consistent with personality disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Psychosis: [Include hallucinations, delusions, or other symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Trauma: [Document symptoms of post-traumatic stress or avoidance behaviors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mental Status Exam:
- [Include observations of appearance, behavior, mood, thought process, insight, and judgment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Tests and Scores:
- [Include results of validated rating scales or diagnostic tests (e.g., PHQ-9, GAD-7)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies:
- [Document any known allergies or adverse medication reactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Review of Systems (General ROS):
- [List other relevant systems or complaints as reported by the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Physical Exam:
- [Include findings from the patient’s physical examination, if conducted] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Vital Signs:
- [Document vital signs including blood pressure, heart rate, respiratory rate, temperature, and O2 saturation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Level of Observation and Precautions:
- [List observation level (e.g., 1:1, Q15min checks) and any precautions such as suicide or elopement risk] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Physical Safety Risks:
- [Document any physical risks such as falls or injuries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Safety Assessment:
- [Include assessment of suicidality, self-harm, or danger to others] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Document protective factors and safety planning] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [Summarize findings, diagnoses, and progress in treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
DSM-5-TR Codes:
- [List all relevant DSM-5-TR diagnostic codes with descriptions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [Include treatment plan components such as medications, therapy, and lifestyle changes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Treatment Changes: [Document any updates or adjustments to treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Follow-Up Email:
- [Summarize visit outcomes, recommendations, and provide contact information for questions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Billing Codes:
- [List appropriate ICD-10 and CPT codes for the visit and services provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
To-Dos:
- [List tasks for the care team, such as referrals, follow-ups, or medication adjustments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Include follow-up actions for the patient, such as completing assessments or attending therapy sessions] (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, or recommendations - 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, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all relevant information from the transcript.)
