Chief Complaint:
Patient presents with persistent low mood, anhedonia, and difficulty sleeping for the past three months.
Past Medical & Psychiatric History:
Diagnosed with Major Depressive Disorder five years ago. Currently taking sertraline 100mg daily. No previous hospitalisations. No other relevant medical conditions.
Family History:
Mother has a history of depression.
Social History:
Employed as a teacher. Reports moderate alcohol consumption (2-3 drinks per week). Has a supportive partner and a close network of friends.
Mental Status Examination:
Appearance: Well-groomed, appears stated age.
Behaviour: Slightly slowed psychomotor activity.
Speech: Normal rate and rhythm.
Mood: Subjectively reports low mood.
Affect: Constricted.
Thoughts: No suicidal or homicidal ideation reported.
Perceptions: No hallucinations or delusions reported.
Cognition: Oriented to person, place, and time. Intact memory.
Insight: Acknowledges the need for treatment.
Judgment: Good.
Risk Assessment:
Suicidality: Denies suicidal ideation or intent.
Diagnosis:
Major Depressive Disorder, moderate severity (F33.1) based on DSM-5 criteria.
Treatment Plan:
Medications: Continue sertraline 100mg daily.
Psychotherapy: Recommend individual cognitive behavioural therapy (CBT).
Follow-up appointments and referrals: Schedule follow-up appointment in four weeks. Referral to a CBT therapist.
Safety Plan:
Patient has identified coping strategies and support contacts.
Chief Complaint:
[Primary mental health issue and presenting symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical & Psychiatric History:
[Past psychiatric diagnoses, treatments, hospitalisations, current medications, or relevant medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Family History:
[Relevant psychiatric illnesses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
[Occupation, level of education, substance use including smoking, alcohol, recreational drugs, social support] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Mental Status Examination:
[Appearance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Behaviour] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Speech] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Mood] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Affect] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Thoughts] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Perceptions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Cognition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Insight] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Judgment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Risk Assessment:
[Suicidality] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Homicidality] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other risks] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis:
[Diagnosis using DSM-5 criteria and/or results from psychological scales/questionnaires] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment Plan:
[Investigations performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Psychotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Family meetings and collateral information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Psychosocial interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Follow-up appointments and referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Safety Plan:
[Steps to take in crisis, if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
