Patient:
DOB:
Consultation date:
Presentation / Current Status:
- Patient’s presenting issues, reasons for today’s consultation, and chief complaints, including symptoms and requests.
- Impact of the client’s presenting concerns on their daily activities.
- How symptoms affect the client’s daily life, work, relationships, and activities.
- Relevant physiological or lifestyle observations that may be impacting mental health (e.g., sleep, appetite, relationship changes).
Risk Assessment & Management:
- Patient’s risk profile considering: suicidal ideation, homicidal ideation, self-harm, violence and aggression, addictive behaviours, risk-taking and impulsivity, and any other issues posing significant risk of harm.
- Any risk management plan and factors that mitigate the level of risk.
Mental Status Examination (MSE):
- Appearance.
- Behaviour.
- Speech.
- Mood and Affect.
- Thought Process.
- Thought Content.
- Perception.
- Cognition.
- Insight and Judgment.
Medical Investigations:
- Results of any medical investigations or readings taken by the psychiatric nurse.
- Include blood pressure, respiratory rate, weight, temperature, etc.
Interventions:
- What the psychiatric nurse did during the consultation.
- Any psychological interventions used (e.g., supportive counselling, CBT, psychoeducation).
- Actions related to medication administration, monitoring, or coordination.
- Current medication dosage and document any changes to medication.
Patient Response:
- Patient’s response to medication and any other interventions.
- Level of engagement, rapport, and therapeutic alliance in the consultation.
- Patient’s overall progress, noting any barriers to reaching treatment goals.
Current Diagnosis:
- Patient’s current psychiatric diagnoses, including accompanying diagnostic codes from DSM-5-TR.
- Differential diagnoses or other diagnostic-specific information mentioned by the psychiatric nurse.
Plan / Follow-Up:
- Plans for follow-up.
- Any tasks or activities assigned to the patient.
- Any tasks the psychiatric nurse will complete (e.g., follow up with key stakeholders, refer to health professionals or services).
- Date and time of the next appointment and any plans related to the next appointment.
Patient: Mary Blogs
DOB: 15 March 1978
Consultation Date: 12 February 2025
Presentation / Current Status:
- Mary presented for scheduled medication review and monitoring following recent increase in sertraline dosage four weeks ago.
- She reports improved mood and reduced anxiety symptoms, though still experiences occasional low mood in mornings.
- Sleep has improved from 4-5 hours to 6-7 hours per night.
- She is managing work attendance more consistently and has resumed some social activities with friends.
Risk Assessment & Management:
- Mary denies current suicidal ideation, self-harm thoughts, or harm to others. She reports previous passive suicidal ideation six weeks ago has completely resolved since medication adjustment.
- No current risk-taking behaviours or substance use concerns identified.
- Protective factors include supportive family, stable employment, engagement with treatment, and improved functioning.
Mental Status Examination (MSE):
Mary presented as well-groomed with appropriate casual attire and good hygiene. She maintained appropriate eye contact with cooperative and engaged behaviour throughout the consultation. Speech was normal in rate, volume, and tone with coherent and goal-directed thought processes. Mood described as “much better, more stable” with congruent euthymic affect showing appropriate range. No evidence of perceptual disturbances, delusions, or cognitive impairment noted, with good insight into her condition and treatment needs.
Medical Investigations:
- Vital signs recorded: Blood pressure 118/76 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, temperature 36.7°C.
- Weight recorded as 68kg, unchanged from previous visit.
- All readings within normal limits with no concerns identified.
Interventions:
- Medication review conducted with assessment of therapeutic response and side effects. Current medication: Sertraline 100mg daily (increased from 50mg four weeks ago). Mary reports no significant side effects apart from mild nausea in first week which has resolved.
- Psychoeducation provided regarding continued medication adherence and expected timeframe for full therapeutic effect.
- Supportive counselling provided regarding strategies for managing residual morning low mood including behavioural activation and morning routine structuring.
Patient Response:
- Mary demonstrated good engagement throughout the consultation with excellent rapport and therapeutic alliance. She showed clear understanding of psychoeducation provided and expressed commitment to continuing current treatment plan.
- She reported feeling optimistic about progress and noted improvements in concentration, energy levels, and motivation. Mary actively participated in discussion of strategies for managing remaining symptoms.
Current Diagnosis:
- Major Depressive Disorder, Recurrent Episode, Moderate (F33.1)
- Generalised Anxiety Disorder (F41.1)
Plan / Follow-Up:
- Continue sertraline 100mg daily with plan to maintain current dosage given positive response.
- Mary to continue implementing behavioural activation strategies and monitor mood patterns, particularly morning symptoms.
- Psychiatric nurse to follow up with treating psychiatrist Dr Sarah Thompson regarding progress and current treatment plan.
- Next appointment scheduled for 12 March 2025 at 10:00am for continued medication monitoring and support.
