Scribe BC- BCCH Progress note

Patient Name: Emily Carter Date of Birth: 12/03/2010 PHN: 9876543210 Referring Provider: Dr. Sarah Jones Location: Outpatient Psychiatry Clinic PSYCHIATRY PROGRESS NOTE I saw Emily Carter in-person for a follow-up appointment on 1 November 2024 from 10:00 AM to 11:00 AM. Caregiver, Mrs. Carter, was present. IDENTIFYING DATA: Emily Carter is a 14-year-old female who lives with her parents. Emily attends high school and is in grade 9, attending regularly. Previous psychiatric diagnoses include Major Depressive Disorder and Generalized Anxiety Disorder. Emily continues to attend individual therapy and is followed through this clinic as well as a therapist at the local community health center. CURRENT MEDICATIONS: * Sertraline 100mg daily * Buspirone 10mg twice daily INTERIM HISTORY Emily reports feeling more stable overall since her last visit. She continues to experience low mood and anxiety, but the intensity and frequency of symptoms have decreased. She reports feeling less overwhelmed by school and social situations. The duration of the low mood is intermittent, lasting a few hours to a few days. The anxiety is triggered by social events and academic pressure. She has been using coping mechanisms learned in therapy, such as deep breathing and mindfulness, which have been somewhat effective. There have been no previous episodes of this severity. The impact on daily activities has lessened, and she is able to attend school and participate in some extracurricular activities. Associated symptoms include fatigue and occasional headaches. MENTAL STATUS EXAMINATION Emily presented as well-groomed and appropriately dressed. Her self-described emotional state was "better" than last time. Her emotional response was congruent with her stated mood. Her thought process was linear and goal-directed, with no evidence of thought disorder. There were no reported hallucinations or perceptual disturbances. She demonstrated good insight into her condition and acknowledged the need for continued treatment. She demonstrated good judgment and decision-making ability. Her memory, orientation to time, place, and person, concentration, and comprehension were intact, however, not formally assessed. PHYSICAL EXAMINATION Vital signs were within normal limits. General appearance was normal. No acute distress was noted. IMPRESSION Major Depressive Disorder and Generalized Anxiety Disorder, currently stable with improved symptoms. Differential diagnosis includes adjustment disorder. PLAN * Continue current medication regimen. * Continue individual therapy weekly. * Review coping strategies and discuss any new challenges. * Next appointment date for psychiatric follow-up in four weeks. It was a pleasure meeting with Emily and Mrs. Carter today. Dr. Thomas Kelly Child and Adolescent Psychiatrist Psychiatry "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."