Identifying Information:
- Detail patient’s name or initials, age, gender, and date of today’s consultation
Reason for Consultation:
- Brief statement of the presenting problem or purpose of the appointment (e.g., follow-up, medication review, evaluation of new symptoms)
Subjective Information:
- Detail the patient’s description of current symptoms, concerns, and goals
- Include any stated changes in mood, behaviour, or functioning since the last visit
- Detail the patient’s perspective on the effectiveness and side effects of current treatment
- Detail any changes in life circumstances or significant life events for the patient
Mental Status Examination (MSE):
If not stated in the transcript, print the subheading and leave blank.
- Appearance: Describe the patient’s general physical appearance, hygiene, grooming, and attire
- Behaviour: Describe the patient’s interaction with their surroundings, activity level, psychomotor activity, eye contact, and rapport
- Speech: Describe the rate, volume, tone, coherence, and articulation of the patient’s speech
- Mood and Affect: Describe the patient’s reported mood and emotional state using their own words if possible, range and appropriateness of emotional response, and any discrepancies with stated mood
- Thought Process: Describe the patient’s coherence, organisation, and flow of thoughts
- Thought Content: Describe the content of the patient’s thoughts, noting presence of delusions, distortions, obsessions, or intrusive thoughts
- Perception: Describe hallucinations or other perceptual disturbances
- Cognition: Describe the patient’s orientation to time/place/person, attention, memory, concentration, and comprehension
- Insight and Judgment: Describe the patient’s understanding of their mental health condition and decision-making capacity
Current Medications:
- List current psychiatric and non-psychiatric medications, including doses and frequencies
- Assess adherence to the prescribed regimen
- Note any reported side effects or concerns about medications
- Include evidence-based reasons and considerations for possible medication adjustments
Assessment:
- Summarise the patient’s clinical presentation and any changes from previous sessions
- Summarise the psychiatrist’s diagnostic impressions based on DSM-5 or ICD-11 criteria
Risk:
- Make risk assessment statement regarding suicidal or homicidal ideation, self-harm or harm to others, and risk of relapse
- Include information about past suicide attempts or self-harming behaviour
- Include psychosocial stressors contributing to risk level
- Describe protective factors that mitigate risk
Plan:
- Specify evidence-based recommendations for medication changes and rationale
- Specify suggested non-pharmacological interventions and rationale
- Specify referrals to other specialists or services and rationale
- Detail plan for follow-up and monitoring
- Detail any Safety Plan made in event of risk to safety
- Summarise education provided about diagnosis and treatment options, documenting patient’s understanding and agreement
Summary:
- Provide a brief paragraph summary of the session
Identifying Information:
- Patient: Mary B., 32-year-old female
- Consultation date: 05/06/2025
Reason for Consultation:
Two-week follow-up appointment to assess response to newly commenced sertraline and monitor mental health symptoms following initial diagnosis of Major Depressive Disorder.
Subjective Information:
Mary reports some improvement in sleep quality since starting sertraline 50mg daily, now sleeping 5-6 hours nightly compared to 3-4 hours previously. She continues to experience low mood but notes less frequent crying episodes and slight improvement in energy levels. Mary reports mild nausea during the first week of medication which has since resolved. She has reduced alcohol consumption to 1-2 glasses of wine weekly as discussed. Custody arrangements have been finalised with shared care agreement reached, which has reduced her legal stress considerably. Mary has commenced weekly psychology sessions and reports finding them helpful for processing her emotions.
Mental Status Examination (MSE):
- Appearance:
- Behaviour: Cooperative and engaged, maintained good eye contact, less tearful than initial consultation
- Speech: Normal rate and volume, clear articulation without tremor noted previously
- Mood and Affect: Self-described mood as “still low but a bit more hopeful,” affect congruent with mild improvement, less restricted range
- Thought Process: Coherent and organised, reduced rumination compared to initial assessment
- Thought Content: Less preoccupied with themes of failure, focuses more on practical planning for future
- Perception: No hallucinations or perceptual disturbances reported
- Cognition: Fully oriented with improved concentration and working memory
- Insight and Judgment: Excellent insight into condition and treatment progress, good judgment regarding medication adherence and lifestyle changes
Current Medications:
- Sertraline 50mg daily – good adherence reported, taking with breakfast to minimise nausea
- Paracetamol as needed for headaches – reduced frequency of use
- Consider increasing sertraline to 100mg daily if further improvement needed at next review
Assessment:
- Mary shows early positive response to sertraline treatment with improvements in sleep, energy, and emotional regulation.
- Clinical presentation demonstrates partial remission of depressive symptoms with reduced severity compared to initial assessment.
- Diagnosis of Major Depressive Disorder, single episode, remains appropriate with current symptoms in mild to moderate range.
Risk:
- Continues to deny suicidal ideation and reports no passive death wishes since commencing treatment.
- Expresses optimism about future and custody arrangements, which serve as protective factors.
- No current risk of self-harm or harm to others identified.
- Reduced alcohol consumption and improved sleep patterns further mitigate risk factors.
Plan:
- Continue sertraline 50mg daily for another four weeks to allow full therapeutic effect. Increase to 100mg daily if insufficient improvement at next review
- Continue weekly psychology sessions focusing on adjustment and coping strategies
- Maintain reduced alcohol consumption and implement regular sleep routine
- Follow-up appointment scheduled in four weeks to assess further progress
- Safety plan reviewed and remains current with instruction to contact crisis services if mood deteriorates
- Psychoeducation reinforced regarding expected timeline for antidepressant response and importance of medication adherence
Summary:
Mary demonstrates early positive response to sertraline treatment with improvements in sleep, energy levels, and emotional stability since commencing antidepressant therapy two weeks ago. Resolution of custody matters has significantly reduced her stress levels and she is actively engaging in psychological therapy. Current plan involves continuing sertraline at present dose with follow-up in four weeks to assess need for dose adjustment. Risk remains low with good protective factors and improved coping strategies.
