Miwatj Review template

Psychiatrist Review Date: Location: Present (list participants): Patient background: [paragraph describing patient demographic factors, social situation, recent collateral history received regarding health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Previous diagnoses: [dot point list of diagnoses discussed using DSM 5 specifiers such as severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical history: Current medications: [dot point list of medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Previous medications: [dot point list of previous medications trialled with reasons for ceasing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: - [Vital signs] (include heart rate, blood pressure, weight, height, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [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 omit completely. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.) - Collateral history: [describe reports from clinic staff or family members about patient's current mental health and functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review: [Patient name] was reviewed at home with [if other clinicians or family present mention so] for [describe reasons for appointment]. This is on a background of [mention previous DSM V diagnoses and any recent changes to treatment or lifestyle]. [Make general comment about functioning in work or school.] [record detailed summary of information including recent social or occupational functioning, recent changes in treatment, current mood, with details on treatment response and side effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [record specific details of mental disorder symptoms and patient response to treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [describe any substance use mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [describe current treatment if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [describe any negative side effects of treatment. If no major side effects identified, write that no major side effects were reported.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mental state: [write one paragraph psychiatric mental state examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Impression: [description of overall impression including DSM 5 diagnosis, impact of diagnosis on functioning and response to treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [comment on patient's response to treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [comment on overall patient functioning and patient strengths] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Today we discussed: [list in dot points any treatment planning discussed and treatment decisions made by patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Recommendations: [numbered list of all the treatment recommendations discussed in the appointment, use "please" when requesting patient do something] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert clinician name] [Insert clinician credentials] (For each section, only include if explicitly mentioned in transcript or context, 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.)